    [Senate Hearing 111-604]
    [From the U.S. Government Publishing Office]

                                                   S. Hrg. 111-604, Pt. 1

                                                            Senate Hearings

                                     Before the Committee on Appropriations

    _______________________________________________________________________

                                                     Departments of Labor,

                                                Health and Human Services,

                                                and Education, and Related

                                                   Agencies Appropriations

                                                           Fiscal Year 2011
                                             111th CONGRESS, SECOND SESSION

                                                                    S. 3686

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

      Departments of Labor, Health and Human Services, and Education, and
           Related Agencies Appropriations, 2011 (S. 3686)--Part 1

    For sale by the Superintendent of Documents, U.S. Government Printing Office,
    http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202�09512�091800, or 866�09512�091800 (toll-free). E-mail, gpo@custhelp.com.

                                               S. Hrg. 111-604, Pt. 1 deg.

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2011

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

                                    HEARINGS

                                    before a

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                         ONE HUNDRED ELEVENTH CONGRESS

                                 SECOND SESSION

                                       on

                                    S. 3686

     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, 2011, AND FOR OTHER PURPOSES

                                   __________

                             Part 1 (Pages 1-572)

                            Department of Education
                    Department of Health and Human Services
                              Department of Labor
                           Nondepartmental Witnesses
                     Corporation for Public Broadcasting
                  Federal Mediation and Conciliation Service
                     Physician Payment Review Commission
                  Prospective Payment Assessment Commission
                       United States Institute of Peace
                        Social Security Administration

                                   __________

             Printed for the use of the Committee on Appropriations

     40 deg. 60 deg.Available via the World Wide Web: http://www.gpo.gov/
                                     fdsys

                                   __________

                          COMMITTEE ON APPROPRIATIONS

                       DANIEL K. INOUYE, Hawaii, Chairman
    PATRICK J. LEAHY, Vermont            THAD COCHRAN, Mississippi,
    TOM HARKIN, Iowa                     CHRISTOPHER S. BOND, Missouri
    BARBARA A. MIKULSKI, Maryland        MITCH McCONNELL, Kentucky
    HERB KOHL, Wisconsin                 RICHARD C. SHELBY, Alabama
    PATTY MURRAY, Washington             JUDD GREGG, New Hampshire
    BYRON L. DORGAN, North Dakota        ROBERT F. BENNETT, Utah
    DIANNE FEINSTEIN, California         KAY BAILEY HUTCHISON, Texas
    RICHARD J. DURBIN, Illinois          SAM BROWNBACK, Kansas
    TIM JOHNSON, South Dakota            LAMAR ALEXANDER, Tennessee
    MARY L. LANDRIEU, Louisiana          SUSAN COLLINS, Maine
    JACK REED, Rhode Island              GEORGE V. VOINOVICH, Ohio
    FRANK R. LAUTENBERG, New Jersey      LISA MURKOWSKI, Alaska
    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

                                  Erik Fatemi
                                  Mark Laisch
                                Adrienne Hallett
                                 Lisa Bernhardt
                           Bettilou Taylor (Minority)
                          Sara Love Swaney (Minority)

                             Administrative Support

                                  Teri Curtin
                          Jennifer Castagna (Minority)

                                C O N T E N T S

                                  ----------

                           Wednesday, March 10, 2010

                                                                       Page

    Department of Health and Human Services: Office of the Secretary.     1

                            Thursday, March 23, 2010

    Department of Labor: Office of the Secretary.....................    51

                           Wednesday, April 14, 2010

    Department of Education: Office of the Secretary.................   109

                             Wednesday, May 5, 2010

    Department of Health and Human Services: National Institutes of
      Health.........................................................   171
    Nondepartmental Witnesses........................................   231

     DEPARTMENTS OF LABOR, HEALTH, AND HUMAN SERVICES, AND EDUCATION, AND
                     RELATED AGENCIES FOR FISCAL YEAR 2011

                                  ----------

                           WEDNESDAY, MARCH 10, 2010

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 3:05 p.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Reed, Pryor, and Cochran.

                    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, Human
    Services, Education and Related Agencies will come to order.
        Well, Madam Secretary, welcome back to the subcommittee. I
    first want to start by commending you for the outstanding work
    you're doing to help enact healthcare reform. We can see the
    finish line at last. And your leadership is one of the reasons
    that we can see that finish line.
        I know it will be tempting for Senators on both sides of
    the dais to want to debate the pros and cons of health reform
    with you today. But I would urge the subcommittee members to
    keep their focus on the subject of our hearing. And that is the
    President's proposed fiscal year 2011 budget for the Department
    of Health and Human Services (HHS).
        On the whole, there's much to like in the HHS budget. As we
    all know the President's budget holds the line on nonsecurity-
    related spending overall in fiscal year 2011. But the President
    promised to use a scalpel, not an ax, to achieve that freeze.
    And HHS is one of the Federal agencies that would get an
    increase, 2.5 percent more than in fiscal year 2010.
        I was particularly pleased that the President included a
    major boost for efforts to root out fraud in Medicare and
    Medicaid. Reducing healthcare fraud and abuse has been a
    priority of mine for many years. And it will play a key role in
    bringing our long-term deficits under control. Significant
    increases were also proposed for the National Institutes of
    Health (NIH), for Head Start, childcare and a new caregiver's
    initiative that will help families take care of their elderly
    relatives.
        Other provisions in the budget raise cause for concern,
    however. For example, the President's budget would cut funding
    for the Centers for Disease Control and Prevention (CDC). The
    budget also includes a $1.8 billion cut to discretionary
    funding under the LIHEAP program. But overall, I think the
    President's budget is a good start. I look forward to
    discussing it in more detail with you during this hearing.
        I also want to add, Madam Secretary, how lucky you are to
    have an Assistant Secretary like Ellen Murray to advise you on
    all these issues. At last year's budget hearing she was sitting
    next to me on the dais. Today she is advising you. I can tell
    you from experience you're in very good hands. And I read it
    just as she wrote that for me right there.
        Senator Harkin. Now I turn to Senator Cochran.

                       STATEMENT OF SENATOR THAD COCHRAN

        Senator Cochran. Mr. Chairman, thank you very much for
    convening the hearing.
        Madam Secretary, we appreciate your being here to talk
    about the budget request. And we look forward to hearing your
    testimony.

                               PREPARED STATEMENT

        I ask unanimous consent that the balance of my remarks be
    placed in the record. I will also include a statement from the
    Chairman, Senator Inouye. He regrets that he could not be
    present.
        Senator Harkin. Thank you very much, Senator Cochran.
        [The statement follows:]

                   Prepared Statement of Senator Thad Cochran

        Mr. Chairman, thank you for chairing this hearing to review the
    budget for fiscal year 2011 for the Department of Health and Human
    Services. We are pleased to welcome the Secretary of Health and Human
    Services, Kathleen Sebelius to her second appearance before our
    subcommittee, and we look forward to working with her to support our
    Nation's investment in healthcare, social services programs, medical
    research, and disease prevention.
        I am pleased that your budget includes a $1 billion increase for
    the National Institutes of Health. These additional dollars are
    essential if we are to continue to make scientific discoveries in
    cancer, autism, heart disease, and the many other maladies that plague
    so many Americans.
        I was also pleased to see your announcement last week regarding the
    $10 million in funds from the America Recovery and Reinvestment Act to
    help communities find ways to curb smoking and combat obesity, improve
    access to healthy foods, and increase physical activity.
        This subcommittee will be challenged to balance the competing needs
    of the programs contained in your $74 billion budget. We look forward
    to working with you to maintain our commitment to fiscal restraint
    while providing much needed increases for high-priority programs.
                                     ______

                 Prepared Statement of Senator Daniel K. Inouye

        Secretary Sebelius, last October Dr. Mary Wakefield, the
    Administrator of the Health Resources and Services Administration,
    visited Hawaii and I would like to thank you for your support of her
    trip. She visited a number of Community Health Centers and toured
    several hospitals and educational facilities on the neighboring
    islands. The people of Hawaii were very grateful to host her visit and
    thankful for the opportunity to discuss critical healthcare concerns of
    the State. In addition she met with representatives from the National
    Kidney Foundation of Hawaii to talk about the increasing incidence of
    kidney disease among the Filipino population.
        Thank you again, and I will provide questions for the record to the
    subcommittee later.

        Senator Harkin. Again, Madam Secretary, welcome back to the
    subcommittee. And again, thank you for your leadership. And
    just by way 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 Governor of Kansas and served in
    that capacity until her appointment as Secretary. Prior to her
    election as governor she served as a Kansas State Insurance
    Commissioner. She is a graduate of Trinity Washington
    University and the University of Kansas.
        Madam Secretary, welcome. Your statement will be made a
    part of the record in its entirety. And please proceed as you
    so desire.

                  SUMMARY STATEMENT OF HON. KATHLEEN SEBELIUS

        Secretary Sebelius. Well, thank you very much, Chairman
    Harkin and Senator Cochran and members of the subcommittee. I
    am glad to be back to discuss the 2011 budget for HHS. I think
    the budget builds on many of the themes that President Obama
    laid out in his State of the Union Address this year,
    strengthening our healthcare system, laying the foundation for
    future growth, and rooting out waste and fraud to make programs
    even more effective.
        Under this budget we plan to make prudent investments in
    our Nation's health and long-term prosperity that members of
    this subcommittee and you, Mr. Chairman, have pushed for years
    in prevention, in wellness, in attacking healthcare fraud and
    supporting our children during those formative, early years and
    in biomedical research that leads to life saving cures to name
    just a few areas. So today I'd like to briefly highlight a few
    of these priorities. And then I look forward to our discussion
    about the issues in this budget.
        Mr. Chairman, as you pointed out many times, what we have
    today in America is a sick/cure system, not a healthcare
    system. And last February, under your leadership, we took a
    huge step in the direction to change the focus of that system.
    With the investments in the Recovery Act we made the single
    largest investment in prevention and wellness in American
    history including the almost $373 million in grants for
    promising local programs that we look forward to releasing in
    the next couple of weeks. Our budget for 2011 builds on this
    investment with new efforts to reduce the harmful effects and
    tremendous costs of chronic disease in the urban populations to
    create a new health prevention corps and prevent unintended
    pregnancies, among other programs that we intend to focus on.
        Senator Cochran, I know that the First Lady recently
    traveled to your home State of Mississippi as part of her
    initiative in the Let's Move campaign to end childhood obesity
    in a generation and highlighted some of Mississippi's very
    successful efforts in this area. And these are exactly the kind
    of promising approaches and strategies that we'd like to make
    sure and place around the country.
        Our budget makes a historic investment in fighting
    healthcare fraud. Again, Mr. Chairman, your subcommittee
    started us on this path 2 years ago with the first
    discretionary funding. We've built on that.
        When American families are struggling to make every dollar
    count we need to be just as vigilant in how we spend their
    money. The new fraud fighting funds will help us expand proven
    strategies like putting Medicare fraud strike forces in cities
    that are hubs for fraudulent activity. And they allow us to
    invest in promising new approaches like systems that will help
    us analyze claims data and suspicious activities in real time.
        When the budget takes effect it's going to be a lot harder
    for criminals to get rich stealing from our healthcare system
    and our seniors. And before you ask, Mr. Chairman, our budget
    does continue the Senior Medicare Control Program which you
    helped to start many years ago and is a great reserve of eyes
    and ears on the ground.
        A third area of focus that I want to highlight for the
    subcommittee is our Early Childhood programs. Again, building
    on the Recovery Act, our budget includes an increase of $1
    billion for Head Start, an extra $1.6 billion for childcare,
    creating room in childcare programs for 235,000 additional
    children. And with these increases we're putting a new focus on
    quality. The years 0 to 5 are at least as important as the
    years that children spend in kindergarten through the 12th
    grade, maybe more important according to the scientists. And
    there's no reason we shouldn't insist on the same high
    standards and the same rigorous focus on results.
        And finally the budget includes a very critical increase of
    nearly $1 billion for the NIH. And I want to thank Chairman
    Harkin and Senator Cochran, Senator Specter and others on this
    subcommittee for their steadfast support for NIH and its
    critical work discovering the building blocks of disease and
    developing the cures of the future. The budget is going to help
    these cures get to American families faster.
        So these are just a few areas in which our budget will
    employ new resources and new approaches to improve the lives of
    American families. I look forward to discussing some of the
    other priorities with you in a few minutes. But first I want to
    just clarify one point.

                               PREPARED STATEMENT

        The budget is intended to be a complement, not a
    substitute, for health insurance reform. The only way to
    increase health security and stability, bring down healthcare
    costs and give Americans better insurance choices is to pass
    comprehensive health insurance reform. Combined with a reform
    effort, the budget is a major step toward building a stronger,
    healthier America. But even then, we'll need your help
    improving the health, safety, and well being of the American
    people. It's a goal we can only achieve by working together.
    And no one has a more important role than Congress.
        So I appreciate the opportunity to be with you today and
    look forward to the discussion.
        [The statement follows:]

                  Prepared Statement of Hon. Kathleen Sebelius

        Chairman Harkin, Senator Cochran, and members of the subcommittee,
    thank you for the invitation to discuss the President's fiscal year
    2011 budget for the Department of Health and Human Services (HHS).
        In his State of the Union Address, President Obama laid out an
    aggressive agenda to create jobs, strengthen opportunity for working
    families, and lay a foundation for long-term growth. His fiscal year
    2011 budget is the blueprint for putting that vision into action.
        At HHS, we are supporting that agenda by working to keep Americans
    healthy, ensuring they get the healthcare they need, and providing
    essential human services for children, families, and seniors.
        Our budget will make sure that the critical health and human
    services our Department offers to the American people are of the
    highest quality and are directly helping families stay healthy, safe,
    and secure--especially as we continue to climb out of a recession.
        It promotes projects that will rebuild our economy by investing in
    next-generation research and the advanced development of technology
    that will help us find cures for diseases, innovative new treatments,
    and new ways to keep Americans safe, whether we are facing a pandemic
    or a potential terrorist attack.
        But this budget isn't just about new programs or new priorities or
    new research. It is also about a new way of doing business with the
    taxpayers' money. Where there is waste and fraud, we must root it out.
    Where there are loopholes, we must close them. And where we have
    opportunities to increase transparency, accountability, and program
    integrity, we must take them. These are top priorities of the
    President. They are top priorities of mine. And our budget reflects
    that they are top priorities for my Department.
        The President's fiscal year 2011 budget for HHS totals $911 billion
    in outlays. The budget proposes $81 billion in discretionary budget
    authority for fiscal year 2011, of which $74 billion is within the
    jurisdiction of the Labor, Health and Human Services, Education, and
    Related Agencies Subcommittee.
        This budget is a major step toward a healthier, stronger America.
    But it is a complement, not a substitute for health insurance reform.
        This administration strongly believes that the only sure way to
    increase health security and stability, bring down healthcare costs,
    and give Americans better insurance choices is to pass comprehensive
    health insurance reform. To that end, the President has put forth a
    proposal that bridges the House and Senate bills and incorporates the
    best ideas of Republicans and Democrats.
        His proposal--which he has called on Congress to swiftly pass--will
    give American families and small business owners more control over
    their healthcare by holding insurance companies accountable. It will
    give Americans protection from insurance company abuses, create a new
    consumer-friendly health insurance marketplace, and begin to bring down
    costs for families, businesses, and Government. Reform is projected to
    reduce the deficit by about $100 billion in the first decade, and
    roughly $1 trillion in the second decade, and, by controlling
    healthcare costs, put the Federal Government on a path to fiscal
    responsibility.
        After meeting last week with the CEOs of America's largest
    insurance companies, who acknowledged that the current health insurance
    system fails to provide transparency and affordable coverage to all
    Americans, I am more convinced than ever that the only way to fix our
    broken health insurance system is to enact these common-sense reforms.
    And after more than 1 year of conversation, Americans deserve an up or
    down vote.
        My hope is that Congress will follow through on the hard work they
    have done over the last 12 months and send a bill to the President
    soon. But for now, I'd like to begin with a broad overview of my
    Department's 2011 budget priorities, many of which are aimed toward the
    same goals. Then I'll look forward to taking some of your questions.
    Investing in Prevention
        Reducing the burden of chronic disease, collecting and using health
    data to inform decisionmaking and research, and building an
    interdisciplinary public health workforce are critical components to
    successful prevention efforts. The budget includes $20 million for the
    Centers for Disease Control and Prevention (CDC) Big Cities Initiative
    to reduce the rates of morbidity and disability due to chronic disease
    in up to 10 of the largest U.S. cities. These cities will be able to
    incorporate the lessons learned from implementing evidence-based
    prevention and wellness strategies of the American Recovery and
    Reinvestment Act of 2009 (Recovery Act) Communities Putting Prevention
    to Work Initiative. This Recovery Act initiative is key to promoting
    wellness and preventing chronic disease, and we appreciate the support
    of Congress, and particularly Chairman Harkin, in making these funds
    available. In March, HHS will award $373 million for the cornerstone of
    this initiative, funding communities to implement evidence-based
    strategies to address obesity, increase physical activity, improve
    nutrition, and decrease smoking. The Big Cities Initiative requested in
    fiscal year 2011 will allow us to build on the success of the Recovery
    Act.
        The budget also includes $10 million at CDC for a new Health
    Prevention Corps, which will recruit, train, and assign a cadre of
    public health professionals in State and local health departments. This
    program will target disciplines with known shortages, such as
    epidemiology, environmental health, and laboratory science.
        To support teen and unintended pregnancy prevention and care
    activities in the Office of Public Health and Science and CDC, the
    budget provides $222 million in funds. Of this, $125 million will be
    used for replicating programs that have proven effective through
    rigorous evaluation to reduce teenage pregnancy; research and
    demonstration grants to develop, replicate, refine, and test additional
    models and innovative strategies; and training, technical assistance
    and outreach. Also, provided in the request is $4 million to carry out
    longitudinal evaluations of teenage pregnancy prevention approaches,
    and another $4 million in Public Health Service evaluation funds for
    this activity. This also includes $22 million for CDC to reduce the
    number of unintended pregnancies through science-based prevention
    approaches. In addition, the fiscal year 2011 Adolescent Family Life
    (AFL) budget includes $17 million to provide support for AFL Care
    demonstration grants and research programs. In an effort to ameliorate
    the negative effects of childbearing on teen parents, their infants and
    their families, care grant community-based projects develop, test, and
    evaluate interventions with pregnant and parenting teens, and focus on
    ways to build and strengthen families.
        Behavioral health is essential to the well-being of all Americans.
    The budget includes an additional $135 million in the Substance Abuse
    and Mental Health Services Administration and Health Resources and
    Services Administration (HRSA) for innovative approaches to prevent and
    treat substance abuse and mental illness. These efforts include
    increases of $35 million for community-based prevention, $25 million to
    expand behavioral health services at health centers, and $17 million
    associated with homelessness prevention. An increase of $13 million
    will expand the treatment capacity of drug courts, and $33 million will
    strengthen our capacity to deter new drug threats and assess our
    progress in reducing substance abuse.
    Reducing Healthcare Fraud
        When American families are struggling to make every dollar count,
    we need to be just as vigilant about how their money is spent. That's
    why the Obama administration is cracking down on criminals who steal
    from taxpayers, endanger patients, and jeopardize the future of our
    health insurance programs.
        Last May, President Obama instructed Attorney General Holder and I
    to create a new Health Care Fraud Prevention and Enforcement Action
    Team, which we call ``HEAT'' for short. HEAT is an unprecedented
    partnership that brings together high-level leaders from both
    departments so that we can share information, spot trends, coordinate
    strategy, and develop new fraud prevention tools.
        As part of this new partnership, we are developing tools that will
    allow us to identify criminal activity by analyzing suspicious patterns
    in claims data. Medicare claims data used to be scattered among several
    databases. If we wanted to find out how many claims had been made for a
    certain kind of wheelchair, we had to go look in several different
    places. This single, searchable database means that for the first time
    ever, we'll have a complete picture of what kinds of claims are being
    filed across the country.
        Our fiscal year 2011 budget includes $1.7 billion in funding to
    fight fraud, including $561 million in discretionary funds to
    strengthen Medicare and Medicaid program integrity activities, with a
    particular emphasis on fighting healthcare fraud in the field,
    increasing Medicare and Medicaid audits, and strengthening program
    oversight while reducing costs. We appreciate the subcommittee's
    support of past requests for fraud prevention; and building on the
    successes we have been able to achieve with those funds, we are now
    seeking an additional $250 million over the fiscal year 2010 level that
    we hope you can support.
        This investment will better equip the Federal Government to
    minimize inappropriate payments, pinpoint potential weaknesses in
    program integrity oversight, target emerging fraud schemes by provider
    and type of service, and establish safeguards to correct programmatic
    vulnerabilities. This multi-year discretionary investment will save
    $9.9 billion over 10 years.
        The budget also includes a set of new administrative and
    legislative program integrity proposals that will give HHS the
    necessary tools to fight fraud by enhancing provider enrollment
    scrutiny, increasing claims oversight, and improving Medicare's data
    analysis capabilities, which will save approximately $14.7 billion over
    10 years. Along with the $9.9 billion in savings from the discretionary
    investments, these new program authorities will save a total of $25
    billion in Medicare and Medicaid expenditures over 10 years.
    Improving Quality of and Access to Healthcare
        At HHS, we continue to find ways to better serve the American
    public, especially those citizens least 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 and the quality of healthcare information and treatments
    through the advancement of health information technology (IT) and the
    modernization of the healthcare system.
        As Congress continues its work to provide security and stability
    for Americans with health insurance and expand coverage to those
    Americans who do not have insurance, HHS maintains its efforts toward
    achieving those goals through activities with the Children's Health
    Insurance Program (CHIP), health IT, patient-centered health research,
    prevention and wellness, community health centers, and the health
    workforce.
        The budget includes $3.6 billion for Centers for Medicare &
    Medicaid Services' (CMS) Program Management. To strengthen the ability
    of CMS to meet current administrative workload demands resulting from
    recent legislative requirements and continued growth of the beneficiary
    population, the funding provides targeted investments to revamp IT
    systems and optimize staffing levels so that CMS can meet the future
    challenges of Medicare, Medicaid, and CHIP while being an active
    purchaser of high-quality and efficient care.
        For example, $110 million will support the first year of a
    comprehensive Health Care Data Improvement Initiative (HCDII) to
    transform CMS's data environment from one focused primarily on claims
    processing to one also focused on state-of-the art data analysis and
    information sharing. Without this funding CMS would not be able to
    transform Medicare and Medicaid into leaders in value-based purchasing
    and in data sources for privacy-protected patient-centered health
    research. This funding is imperative for CMS to meet the needs of
    future growth, financial accountability, and data content and
    availability. The HCDII is the cornerstone of a business strategy that
    will optimize the delivery of efficient, high-quality healthcare
    services. CMS needs this funding to strengthen disaster recovery and
    security operations to protect against loss of data or services; to
    enable timely data sharing and analysis to fight fraud, waste, and
    abuse; and to transform payment processes to support quality outcomes.
        To strengthen and support our Nation's healthcare workforce, the
    budget includes $1.1 billion within the HRSA for a wide range of
    programs. This funding will enhance the capacity of nursing schools,
    increase access to oral healthcare through dental workforce development
    grants, target students from disadvantaged backgrounds, and place an
    increased emphasis on ensuring that America's senior population gets
    the care and treatment it needs.
        The budget includes an increase of $290 million to ensure better
    access to health centers through further expansions of health center
    services and integration of behavioral health into health centers'
    primary care system. This funding builds on investments made under the
    Recovery Act and will enable health centers to serve more than 20
    million patients in fiscal year 2011, which is 3 million more patients
    than were served in fiscal year 2008.
        The budget advances the President's health IT initiative by
    accelerating health IT adoption and electronic health records (EHR)
    utilization--essential tools for modernizing the healthcare system. The
    budget includes $78 million, an increase of $17 million, for the Office
    of the National Coordinator for Health Information Technology to
    continue its current efforts as the Federal health IT leader and
    coordinator. During fiscal year 2011, HHS will also begin providing an
    estimated $25 billion over 10 years of Recovery Act Medicare and
    Medicaid incentive payments primarily to physicians and hospitals who
    demonstrate meaningful use of certified EHRs, which will improve the
    reporting of clinical quality measures and promote healthcare quality,
    efficiency, and patient safety.
        The budget supports HHS-wide patient-centered health research,
    including an additional $261 million within the Agency for Healthcare
    Research and Quality over fiscal year 2010. HHS also continues to
    invest the $1.1 billion provided by the Recovery Act to improve
    healthcare quality by providing patients and physicians with state-of-
    the-art, evidence-based information to enhance medical decision-making.
    Promoting Public Health
        Whether responding to pandemic flu or researching major diseases,
    HHS will continue its unwavering commitment to keeping Americans
    healthy and safe.
        The budget includes more than $3 billion, an increase of $70
    million, for CDC and HRSA to enhance HIV/AIDS prevention, care, and
    treatment. This increase includes $31 million for CDC to integrate
    surveillance and monitoring systems, address high-risk populations, and
    support HIV/AIDS coordination and service integration with other
    infectious diseases. The increase also includes $40 million for HRSA's
    Ryan White program to expand access to care for underserved
    populations, provide life-saving drugs, and improve the quality of life
    for people living with HIV/AIDS.
        To improve CDC's ability to collect data on the health of the
    Nation for use by policy makers and Federal, State, and local leaders,
    the budget provides $162 million for health statistics, an increase of
    $23 million above fiscal year 2010. This increase will ensure data
    availability on key national health indicators by supporting electronic
    birth and death records in States and enhancing national surveys.
        The budget includes $222 million, an increase of $16 million, to
    address Autism Spectrum Disorders (ASD). Research at the National
    Institutes of Health (NIH) will pursue comprehensive and innovative
    approaches to defining the genetic and environmental factors that
    contribute to ASD, investigate epigenetic changes in the brain, and
    accelerate clinical trials of novel pharmacological and behavioral
    interventions, CDC will expand autism monitoring and surveillance and
    support an autism awareness campaign, and HRSA will increase resources
    to support children and families affected by ASD through screening
    programs and evidence-based interventions.
        The budget includes $352 million, an increase of $16 million, for
    CDC Global Health Programs to build global public health capacity by
    strengthening the global public health workforce; integrating maternal,
    newborn, and child health programs; and improving global access to
    clean water, sanitation, and hygiene. Specifically, CDC will expand
    existing programs and develop programs in new countries to provide
    workforce training in areas such as epidemiology and outbreak
    investigation, and to implement programs that distribute water quality
    interventions to create safe drinking water. In addition, CDC will
    integrate interventions, such as malaria control measures, expanded
    immunizations, and safe water treatment, to reduce newborn, infant, and
    child mortality. Additionally, the budget includes $6 million in the
    Office of Global Health Affairs to support global health policy
    leadership and coordination.
    Protecting Americans From Public Health Threats and Terrorism
        Continued investments in countermeasure development and pandemic
    preparedness will help ensure that HHS is ready to protect the American
    people in either natural or manmade public health emergencies. The
    budget includes $476 million, an increase of $136 million, for the
    Biomedical Advanced Research and Development Authority to sustain the
    support of next-generation countermeasure development in high-priority
    areas by allowing the BioShield Special Reserve Fund to support both
    procurement activities and advanced research and development.
        Reassortment of avian, swine, and human influenza viruses has led
    to the emergence of a new strain of H1N1 influenza A virus, 2009 H1N1
    flu, that is transmissible among humans. On June 24, 2009, Congress
    appropriated $7.65 billion to HHS for pandemic influenza preparedness
    and response to 2009 H1N1 flu. HHS has used these resources to support
    States and hospitals, to invest in the H1N1 vaccine production, and to
    conduct domestic and international response activities. The budget
    includes $302 million for ongoing pandemic influenza preparedness
    activities at CDC, NIH, Food and Drug Administration, and the Office of
    the Secretary for international activities, virus detection,
    communications, and research. In addition, the use of balances from the
    June 2009 funds, will enable HHS to continue advanced development of
    cell-based and recombinant vaccines, antivirals, respirators, and other
    activities that will help ensure the Nation's preparedness for future
    pandemics. Previous appropriations for H5N1 allowed us to be better
    prepared for H1N1 than we ever would have been otherwise, and only by
    continued work on better vaccines, antivirals, and preparedness will we
    be ready for the next virus--which could well be a greater challenge
    than H1N1 has been.
    Improving the Well-being of Children, Seniors, and Households
        In addition to supporting efforts to increase our security in case
    of an emergency, the HHS budget also seeks to increase economic
    security for families and open up doors of opportunity to those
    Americans who need it most.
        The budget provides critical support of the President's Zero to
    Five Plan to enhance the quality of early care and education for our
    Nation's children. The budget lays the groundwork for a reauthorization
    of the Child Care and Development Block Grant and entitlement funding
    for childcare, including a total of $6.6 billion for the Child Care and
    Development Fund, an increase of $800 million in the Child Care and
    Development Block Grant and $800 million in the Child Care Entitlement.
    These resources will enable 1.6 million children to receive child care
    assistance in fiscal year 2011, approximately 235,000 more than could
    be served in the absence of these additional funds.
        The administration's principles for reform of the Child Care and
    Development Fund include establishing a high standard of quality across
    childcare settings, expanding professional development opportunities
    for the childcare workforce, and promoting coordination across the
    spectrum of early childhood education programs. The administration
    looks forward to working with Congress to begin crafting a
    reauthorization proposal that will make needed reforms to ensure that
    children receive high-quality care that meets the diverse needs of
    families and fosters healthy child development.
        To enable families to better care for their aging relatives and
    support seniors trying to remain independent in their communities, the
    budget provides $102.5 million for a new Caregiver Initiative at the
    Administration on Aging. This funding includes $50 million for
    caregiver services, such as counseling, training, and respite care for
    the families of elderly individuals; $50 million for supportive
    services, such as transportation, homemaker assistance, adult daycare,
    and personal care assistance for elderly individuals and their
    families; and $2.5 million for respite care for family members of
    people of all ages with special needs. This funding will support
    755,000 caregivers with 12 million hours of respite care and more than
    186,000 caregivers with counseling, peer support groups, and training.
        Funding for the Head Start program, run by the Administration for
    Children and Families (ACF), will increase by $989 million to sustain
    and build on the historic expansion made possible by the Recovery Act.
    In fiscal year 2011, Head Start will serve an estimated 971,000
    children, an increase of approximately 66,500 children over fiscal year
    2008. Early Head Start will serve approximately 116,000 infants and
    toddlers, nearly twice as many as were served in fiscal year 2008. The
    increase also includes $118 million to improve program quality, and the
    Administration plans to implement key provisions of the 2007 Head Start
    Act reauthorization related to grantee recompetition, program
    performance standards, and technical assistance that will improve the
    quality of services provided to Head Start children and families.
        The budget proposes a new way to fund the Low Income Home Energy
    Assistance Program to help low-income households heat and cool their
    homes. The request provides $3.3 billion in discretionary funding. The
    proposed new trigger would provide, under current estimates, $2 billion
    in mandatory funding. Energy prices are volatile, making it difficult
    to match funding to the needs of low-income families, so under this
    proposal, mandatory funds will be automatically released in response to
    quarterly spikes in energy prices or annual changes in the number of
    people living in poverty.
    Investing in Scientific Research and Development
        The investments that HHS is proposing in our human services budget
    will expand economic opportunity, but another critical way to grow and
    transform our economy is through a healthy investment in research that
    will not only save lives but also create jobs.
        The budget includes a program level of $32.2 billion for NIH, an
    increase of nearly $1 billion, to support innovative projects ranging
    from basic to clinical research, as well as including health services
    research. This effort will be guided by NIH's five areas of exceptional
    research opportunities: supporting genomics and other high-throughput
    technologies; translating basic science into new and better treatments;
    reinvigorating the biomedical research community; using science to
    enable healthcare reform; and focusing on global health. The
    administration's interest in the high-priority areas of cancer and
    autism fits well into these five NIH theme areas. In fiscal year 2011,
    NIH estimates it will support a total of 37,001 research project
    grants, including 9,052 new and competing awards.
    Recovery Act
        Since the Recovery Act was passed in February 2009, HHS has made
    great strides in improving access to health and social services,
    stimulating job creation, and investing in the future of healthcare
    reform through advances in health IT, prevention, and scientific
    research. HHS Recovery Act funds have had an immediate impact on the
    lives of individuals and communities across the country affected by the
    economic crisis and the loss of jobs.
        As of September 30, 2009, the $31.5 billion in Federal payments to
    States helped maintain State Medicaid services to a growing number of
    beneficiaries and provided fiscal relief to States. NIH awarded $5
    billion for biomedical research in more than 12,000 grants. Area
    agencies on aging provided more than 350,000 seniors with more than 6
    million meals delivered at home and in community settings. Health
    Centers provided primary healthcare services to more than 1 million new
    patients.
        These programs and activities will continue in fiscal year 2010, as
    more come on line. For example, 64,000 additional children and their
    families will participate in a Head Start or Early Head Start
    experience. HHS will be assisting States and communities to develop
    capacity, technical assistance and a trained workforce to support the
    rapid adoption of health IT by hospitals and clinicians. The CDC will
    support community efforts to reduce the incidence of obesity and
    tobacco use. New research grants will be awarded to improve health
    outcomes by developing and disseminating evidence-based information to
    patients, clinicians, and other decision-makers about what
    interventions are most effective for patients under specific
    circumstances.
        The Recovery Act provides HHS programs an estimated $141 billion
    for fiscal years 2009-2019. While most provisions in HHS programs
    involve rapid investments, the Recovery Act also includes longer-term
    investments in health IT (primarily through Medicare and Medicaid). As
    a result, HHS plans to have outlays totaling $86 billion through fiscal
    year 2010.
    Conclusion
        This testimony reflects just some of the ways that HHS programs
    improve the everyday lives of Americans. Under this budget, we will
    provide greater security for working families as we continue to recover
    from the worst recession in our generation. We will invest in research
    on breakthrough solutions for healthcare that will save money, improve
    the quality of care, and energize our economy. And we will push forward
    our goal of making Government more open and accountable.
        My Department cannot accomplish any of these goals alone. It will
    require all of us to work together. And I am eager to work with you to
    advance the health, safety, and well-being of the American people.
    Thank you for this opportunity to speak with you today. I look forward
    to answering your questions.

        Senator Harkin. Thank you very much, Madam Secretary. And
    we'll start 5-minute rounds, whoever is keeping this clock
    going here. Who keeps the clock going? There we go.

                            WASTE, FRAUD, AND ABUSE

        Madam Secretary again, I applaud you for your continued
    efforts in the waste, fraud, and abuse areas. We have figures
    that show how much money we save when we invest in that.
        I think for every $1 we spend we save $6 and that's real
    money. And the largest portion, the Medicare Integrity Program,
    we get $14 for every $1 we spend. So from the standpoint of
    just economics it's important, but also to provide more
    integrity of the programs. So I applaud you for that.

                          H1N1 EMERGENCY SUPPLEMENTAL

        Another thing I wanted to cover with you was the emergency
    supplemental funding we appropriated last year. We appropriated
    $7.65 billion to address the critical needs relating to the
    emerging H1N1 influenza virus. But in the 2011 budget request
    I've noticed you're using $555 million from this emergency
    supplemental for things that we usually fund in our annual
    appropriations bill. These are the annual costs for flu
    preparedness activities at CDC and in the Office of the
    Secretary.
        I understand it also includes staff salaries. These costs
    can hardly be called an emergency. Can you just tell me how you
    justify these emergency supplemental fundings for these types
    of ongoing costs?
        Secretary Sebelius. Mr. Chairman, it was our goal in
    seeking 2011 funding to be mindful of the budget situation and
    the President's desire not to increase discretionary funding
    for 3 years starting this year. And recognizing that, first of
    all the appropriations made by this subcommittee over time and
    certainly the supplemental funding helped us be very well
    prepared to face the pandemic that arrived here in April with a
    new vaccine, with a very robust outreach effort. But as you
    know when we requested supplemental funding it was still
    anticipated that we might need two doses per person. We were
    not at all certain how lethal the disease would be.
        We were building a contingency plan based on the best
    possible preparedness activities. What we found ourselves, as
    the second wave of the flu has dramatically decreased, that we
    are still working with State and local efforts to have people
    vaccinated. But we have additional funding and we thought
    rather than seeking new funds from the subcommittee process
    that we'd be more appropriate to use for ongoing flu efforts.
    The efforts they're being used for are pandemic efforts that,
    as you know, are underway year in and year out whether we're in
    the midst of a pandemic or not.
        So the CDC activities will continue on. Our work with State
    and local partners will continue on. The kind of staff support
    that you mentioned is part of the preparedness efforts that are
    underway year in and year out. But we just decided not to bank
    that money and then seek additional funds from the
    subcommittee, but use the funds that were available in an
    effort to be as prudent as possible.

                            EARLY CHILDHOOD PROGRAMS

        Senator Harkin. Very good. I appreciate that.
        As a matter of fact, one other area that I've been a long-
    time supporter of is early childhood programs. On the education
    side I've talked a great deal with your counterpart, Secretary
    Duncan. As we both know many States have shown that children
    who receive high-quality, early childhood services are less
    likely to commit crimes, more likely to graduate from high
    school, more likely to hold a job and everything. But the key
    seems to be whether the services are indeed high quality.
        The National Head Start Impact Study released last month
    shows that most of the gains that children show after
    participating in these programs tend to wear off after first
    grade. And this is troubling. So we have to make sure that the
    quality of early childhood programs is consistently high.
        And could you just talk for a minute about how you plan to
    address the quality issue in the 2011 budget request?
        Secretary Sebelius. Absolutely. Mr. Chairman, I share your
    concern that it's always a key issue for parents to have their
    children in safe childcare situations. But I think more
    importantly or as important is to make sure that they are
    actually developing the skills that they're ready to learn once
    they hit kindergarten. And too often that doesn't happen in
    many of the childcare settings.
        So the study that you mention is a snapshot of some years
    ago of what the results were of Head Start programs. And I can
    assure you that there have been a number of investments in
    quality since that snapshot was taken. But even more
    importantly this year we share the notion that we have to
    greatly enhance quality.
        And too often there are somewhat erratic standards at the
    State level. Some States have set very high-quality standards.
    Others have not.
        So we are actually applying some of the funding this year
    for the additional Head Start money to quality standards that
    would be developed and implemented across the country to make
    sure that whether you're in Arkansas or Rhode Island or Iowa or
    Mississippi in a Head Start program that you would anticipate
    the same high-quality standards and that that would be part of
    the funding going forward.
        Senator Harkin. Is that $118 million?
        Secretary Sebelius. Yes, sir. I'm sorry. Yes, we didn't
    apply all of the funding to slots. We think quality
    enhancements nationwide are a critical part of this effort.
        Senator Harkin. Thank you, Madam Secretary. Senator
    Cochran.

                              LET'S MOVE CAMPAIGN

        Senator Cochran. Madam Secretary, thank you very much for
    being here to discuss the budget request before the
    subcommittee. We appreciate some of the highlights you outlined
    and of your intentions as Secretary to solve some of the
    problems that face many of us back in our States. And I noticed
    right away you're putting an emphasis on obesity and you have
    called attention to the fact that the First Lady came to
    Mississippi to talk about the Let's Move campaign, more
    activity, more healthy eating practices. And we surely need
    that in our State.
        And so I was pleased to see that the emphasis is being
    placed by your Department and also at the White House on doing
    something about this really big problem. In Mississippi we win
    the prize. We're number one in childhood and adult obesity.
        So we welcome these efforts. And we hope that we can work
    with the Department to put the money where the problem is and
    let you show us what can be done. And we need leadership. And
    we welcome that.
        Do you have any specific things to tell us about what the
    elements of this program might be?
        Secretary Sebelius. Well, Senator Cochran, in the Let's
    Move campaign the First Lady has really outlined four principal
    goals. And HHS will be involved in a number of them. More tools
    and information for parents to make good choices and that's
    everything from our Food and Drug Administration (FDA) looking
    at new, easier to read, easier to find food labeling to the CDC
    updating and clarifying nutrition standards.
        So parents who want to shop smarter, buy healthier food
    will be able to find it on a grocery shelf and not have to read
    some dense barcode on the back of a package. Pediatricians have
    stepped up saying that they are in agreement that every child
    who gets a checkup should have a body mass index. But more than
    just having the body mass index on a regular basis,
    pediatricians need to have a conversation with the parents
    about what it means. And literally write prescriptions for more
    exercise and/or healthier eating habits. Helping parents,
    again, to make some choices that matter.
        A second pillar is focused on schools where kids spend a
    lot of their time. The Department of Agriculture is working to
    upgrade what's fed to children in school breakfast and school
    lunch programs. And make it healthier and more nutritious
    working again with the CDC on nutrition guidelines.
        The physical education component of schools has kind of
    fallen off the radar screen in too many cases. And what we know
    from the Secretary of Education studies is that not only are
    children healthier, but they actually are better learners if
    they actually move around some during the course of the school
    day.
        So reinstituting physical education will be part of school.
    Working with soft drink manufacturers on marketing sugary
    beverages inside schools and a lot of activity has been done so
    far in terms of voluntarily removing high-sugar content drinks
    from schools and substituting water and juices. So that's kind
    of component number two.
        Number three is we've got 23 million Americans who live in
    so-called food deserts where they don't have access to fresh
    fruits and vegetables. So they may want to eat in a healthier
    manner, but they literally don't have any place within 2 miles
    of their home to go buy a piece of fruit or a fresh vegetable.
        So again the Department of Agriculture is not only doing
    mapping of those so-called food deserts. But looking at
    initiatives with local farmers, local grocers, to try and
    establish a different protocol. We have some dollars available
    in our budget for helping to subsidize some of those healthier
    choices and figure out if it's a price strategy or an access
    strategy.
        And the fourth component of Let's Move is let's see, I'm
    blanking on it for a moment. Parents and kids and--I'll get
    back to you on this and submit the information at a later date.
        [The information follows:]

        Physical Activity.--The fourth component of the Let's Move campaign
    is increasing physical activity. The administration will encourage
    children to be more physically active each day rather than spending
    more time watching TV and playing video games.

        Senator Cochran. Health centers. One thing to do is to use
    the health centers as a place--
        Secretary Sebelius. That--
        Senator Cochran. For the children that go to Head Start
    programs there, the parents can come in and visit with
    healthcare professionals who are there at those centers.
        Secretary Sebelius. Ok.
        Senator Cochran. We found in our State that bringing all
    these programs together in one location certainly helps a lot,
    particular to the very young, those who haven't started
    elementary school. And you can't start too early.
        Secretary Sebelius. Absolutely.
        Senator Cochran. I think a lot of these habits are formed
    very early. And I'm sure you are aware of that. One area of our
    State, the Mississippi Delta, has had great success in
    developing a Delta Health Alliance.
        And I hope that we can see funding directed to programs
    like that so that we can continue to see progress that can be
    made. Local medical centers using Mississippi Valley State
    University, Delta State University, University of Mississippi,
    and Mississippi State University, all have roles to play in our
    State in that effort. So thank you for getting off to such a
    good start in mapping out a plan of action.
        Secretary Sebelius. Well and Senator, I look forward to
    learning the lessons that are already being enacted in
    Mississippi. I know your governor and the First Lady of
    Mississippi have taken a real interest and effort in this area.
    And I absolutely agree that community health centers can play
    an enormously important role.
        Senator Cochran. Thank you.
        Secretary Sebelius. Thank you.
        Senator Harkin. Senator Reed.

                  LOW INCOME HOME ASSISTANCE PROGRAM (LIHEAP)

        Senator Reed. Thank you, Mr. Chairman.
        Madam Secretary, thank you very much.
        The chairman already alluded to the issue of LIHEAP funding
    which is critical not only to my State but to practically every
    State in both the cold winter States and the very, very hot
    summer States. The chairman over the last few years, ensured
    that we've had very robust funding. This $2 billion reduction
    to the LIHEAP Block Grant will translate into a $13.6 million
    cut for Rhode Island, which is a sizable number for us.
        And also it undercuts the certainty of planning in terms of
    what monies they might have. I know you're creating a mandatory
    stream of funding with a trigger that will kick in when prices
    rise or when economic conditions worsen, but all of that I
    think will be discounted because it will be so difficult to
    anticipate these conditions. And essentially States will be
    planning for and allocating and getting a waiting list on the
    basis of a lower block grant.
        The other issue too, is that this trigger is going, I
    think, to be difficult to sort of estimate when it precisely
    kicks in. And also it's unclear to me what the formula for
    distribution is if the trigger kicks in. And by way of that,
    this January there was contingency money released to the
    States. Rhode Island actually got $4 million less than the
    previous year at a time when our employment sadly, is second or
    third in the Nation. So the subjectivity of distribution of
    this funding is going to, I think, contribute to significant
    concerns.
        My question, I think, is can we do better?
        One, in terms of the baseline number?
        Two, how do you specifically propose to resolve the trigger
    and the distribution formula?
        Secretary Sebelius. Well Senator, let me just start by
    saying I, first of all, not only appreciate the interest and
    leadership in the LIHEAP program in the past, but also
    recognize as a governor who distributed LIHEAP funds how
    essential it is to people who cannot pay their bills in the
    winter and some in the summer. So I know what a critical safety
    net that is.
        In terms of the distribution methodology this year which I
    know again, was a subject of some concern, particularly in the
    Northeast. We looked at two factors for the money that was
    distributed in January.
        One was the cost of heating oil, which had come down to
    some degree over where we had been in the previous year, but in
    addition to that, the number of States who were actually
    experiencing unusually cold winters. And there were States that
    were far more scattered than some patterns we had seen in the
    past. And added to that the unemployment index as an indicator
    of States in real economic hardship.
        And as you know 14 States were deemed to be, not by our
    count, but by the weather assessments, 5 percent colder during
    those winter months than had been experienced in the past. And
    we then distributed the money, some additional money to those
    14 States as well as a formula grant to the others based on
    what we were seeing. There still is a pot of money for the
    LIHEAP funding this year that is still being held anticipating
    either further distributions this winter or in the summer
    months having some real spikes in temperature that require
    additional distributions.
        In terms of the proposition for 2011 and the trigger
    proposal, there is a $3.3 billion discretionary fund, but then
    a $2 billion mandatory fund that would activate with a trigger,
    which would result actually in an increase in the overall
    LIHEAP funding for 2011, not a decrease in funding. And the
    combination trigger would be based on the analysis of the cost
    of energy plus an assessment of the poverty population in a
    State based on who is eligible for the Supplemental Nutrition
    Assistance Program. So it would be again, not our subjective
    look at it. But it would look at eligibility for the food and
    nutrition program combined with the heating oil prices for the
    winter.
        We anticipate that if energy prices are high and people are
    having a struggle paying their bills the trigger would be met.
    And again, having the poverty sensitivity would help enhance
    that ability and the formula would be divided according to the
    population. So I know that there was some discussion last year
    on our budget about a formula that just looked at the price of
    winter fuel.
        And we thought the addition of a recognition that this is
    an economic downturn and this is about people paying their
    bills. So, to look at who is in economic difficulty along with
    the price made a lot more sense and made the trigger a lot more
    sensitive.
        Senator Reed. Just two points because my time expired.
        One is let us go over so the numbers because I have an
    indication that if you look at the formula money plus the
    trigger money it won't be as much as previous years. But that
    might be my miscalculation.
        Secretary Sebelius. We would love to get the--yes. We'd
    love to get that.
        Senator Reed. The second point is even in the best of times
    when the economy is doing very well and the temperature is
    relatively mild, there are long, long waiting lists in my State
    and other States. So this notion of needing a trigger because,
    the demand only comes up during economic crises is not
    substantiated by the facts. But I thank the chairman for his
    indulgence.
        Thank you, Madam Secretary.
        Secretary Sebelius. Well then Senator I would volunteer
    that we would love to work with you on this.
        Senator Reed. Well, thank you.
        Secretary Sebelius. First, getting you the numbers and
    making sure we're on the same page and then talking to you
    about--because I think we share the same goal that we don't
    want people struggling to pay their heating bills or having to
    turn off the heat when they can't pay them. So we want to work
    with you.
        [The information follows:]

                                                     LIHEAP FUNDING
                                                [In millions of dollars]
    ----------------------------------------------------------------------------------------------------------------
                                                                                        Fiscal year
                                                                        Fiscal year        2011          Increase/
                                                                           2010         President's      decrease
                                                                       appropriation      budget
    ----------------------------------------------------------------------------------------------------------------
    Discretionary...................................................           5,100           3,300          -1,800
    Mandatory trigger \1\...........................................  ..............           2,000          +2,000
                                                                     -----------------------------------------------
          Total.....................................................           5,100           5,300            +200
    ----------------------------------------------------------------------------------------------------------------
    \1\ For scoring purposes, $2 billion is assumed for fiscal year 2011.

        Senator Reed. Thank you, Madam Secretary. Thank you.
        Senator Harkin. Thank you very much. And I just personally
    want to thank you, Senator Reed, for your leadership in this
    area. You've been stalwart on that. And I look forward to
    making sure you get this all worked out for us.
        Senator Pryor.
        Senator Pryor. Thank you, Mr. Chairman. Madam Secretary,
    welcome once again to the subcommittee. It's always good to see
    you. I believe the administration has made a commendable effort
    to reduce waste, fraud, and abuse in healthcare programs both
    in its budget request and in its healthcare reform proposal.
        What support do you need from this subcommittee in the
    appropriations process as it moves forward to ensure that we're
    taking the necessary steps to end, as much as humanly possibly,
    waste, fraud, and abuse in our public health programs?
        Secretary Sebelius. Well, Senator, I'm glad you asked that
    question.
        First of all, let me just reiterate that I think the
    President takes this effort very, very seriously. It's one of
    the reasons he asked the Attorney General and me to, as Cabinet
    officers, convene a joint effort. And we are working very well
    with the Justice Department, and the strike forces now that are
    in seven cities are really paying off, big results.
        So the budget has a couple of requests.
        One is an additional $250 million in discretionary funding,
    which would allow us to expand the footprint of those strike
    forces. And as you heard Chairman Harkin say, we know that
    every dollar invested returns multiple dollars. And that's just
    dollars we get back in the door for prosecutions and can return
    to the fund and make the Medicare fund more solvent. I think
    there's an additional impact that is impossible to measure,
    which is that we discourage people from committing crimes in
    the first place by making it very clear that we intend to
    prosecute vigorously and come after them. So that's one piece
    of the puzzle.
        Another big piece of the puzzle is a data system request
    that is in for the CMS budget, about $110 million to begin a
    multiyear process to upgrade our system. What we miss right now
    is the ability to look at data sets in one system. Medicare is
    the biggest health insurance program, I think, in the world. We
    pay out--we pay more than $1 billion in claims to providers
    over the course of the year; more than $500 billion worth of
    benefits every year.
        We still have those data sets in multiple places. So it's
    impossible to check errant behavior unless you check six or
    seven systems. We have a plan that has been developed that by
    the end of 2011 we would be at a real time, one data set,
    flexible ability to share that data with law enforcement
    officers.
        To do the same thing that frankly major credit card
    companies can do, which is watch what's happening.
        Senator Pryor. Right.
        Secretary Sebelius. And immediately go after folks. And we
    need more boots on the ground.
        Senator Pryor. Yes. I think it's great that you say that.
    I'm glad to know that you're on top of that because when I was
    the State's attorney general we did the Medicaid fraud piece of
    enforcement.
        Secretary Sebelius. Yes.
        Senator Pryor. And on all those cases, you know, we would
    do these extensive investigations and all this but it was
    always after the fact.
        Secretary Sebelius. Pay and chase.
        Senator Pryor. Oftentimes it was 1 or 2 years later and
    some of these people you can never find again.
        Secretary Sebelius. Right.
        Senator Pryor. Or they've been doing this for so long
    you're never going to get the money back from them or whatever
    the case may be. I support the idea of trying to get to a point
    where we can go to real time. You mentioned credit card
    companies. But also other health insurance companies do that
    where they're able to look at claims in real time.
        I mean literally when someone is at the register they will
    get a prompt. I don't know how it works. But under what they're
    doing, the insurance company will be able to say, ``No, we need
    to check on this right now.''
        So it's out there. We can do this. We can do this a lot
    smarter. And I think we can save tens of billions of dollars
    every year by doing that.

                 GEOGRAPHIC VARIANCE IN MEDICARE REIMBURSEMENT

        We have a concern in Arkansas on what we call geographic
    variance in Medicare reimbursement. You know that issue very
    well. And I'm sure in your home State you may have some of this
    as well.
        But if healthcare reform is enacted and I know that's not a
    certainty as we speak. But if it is, will you work to ensure
    that any geographic variations in reimbursement are fairly
    calculated and do not discriminate against rural America?
        Secretary Sebelius. Well, Senator, as you said, I'm very
    familiar with the difficulty often of providing quality health
    services in more rural areas. And the cost estimations have to
    be calculated about what it requires to do that. So I would
    love to work with you and other members. As you know, Senator,
    I like to refer to your State as ``Our Kansas.''
        So I think we are sister States and we----
        Senator Pryor. We have--and that's exactly right.
        Secretary Sebelius. But yes, I would very much like to work
    with you on that issue.
        Senator Pryor. Great.

                             PANDEMIC PREPAREDNESS

        The last question I have for this round is I know we've
    been through the H1N1 flu pandemic and I'm sure different
    people would agree or disagree about how well that was managed
    by the Federal Government. But what does the administration's
    budget doing to put us in an even better position this coming
    flu season and the years to come to handle either H1N1 or some
    other pandemic?
        Secretary Sebelius. Well, Senator, the ongoing efforts of
    pandemic planning continue. And the budget, I think, through
    the CDC, through our hospital preparedness grants, through our
    partnership efforts with State and local governments continues
    to ramp that up. I don't think there's any question of that--
    and this subcommittee was really instrumental in helping those
    years of preparation so that this year when something hit we
    were really far more prepared than we would have been if we
    were facing it for the first time.
        We are in the process and I look forward, Mr. Chairman, to
    coming back to this subcommittee and others in an entire
    systemwide review. Not just H1N1, but really our whole
    countermeasures effort. We think it's appropriate to use this
    most recent situation as a way to say how prepared are we for
    whatever comes at us next, whether it's a pandemic that we get
    some warning for and know something about and know what kind of
    vaccine or a dirty bomb on a subway.
        What did we learn?
        Where are the gaps in the system?
        Where are the efforts that we need to move forward?
        We know we need more manufacturing capacity for vaccine.
    That was very clear.
        We know we need different technology for vaccine
    production. You know, the time table of growing virus in eggs
    is slow. And that needs to ramp up.
        But we need to look at the whole system. And that's
    underway. And we anticipate when you return from the break in a
    couple of weeks we will have an ability to report back on a
    whole range of lessons learned from H1N1.
        Senator Pryor. Great. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Pryor.

               VACCINE PRODUCTION AND DISTRIBUTION INFRASTRUCTURE

        Just to follow up, if the pandemic did not happen, I am
    concerned that we then start to think, ``Welll, that was just a
    scare anyway. It really wasn't going to happen.''
        Now we fall into lethargic mode by thinking that we can
    delay implementation of preventative measures. You put your
    finger on it. We have to build the structures.
        Secretary Sebelius. You bet.
        Senator Harkin. That can respond more rapidly, cell-based
    systems so we can grow the viruses or RNA-based systems that,
    can even be more rapidly utilized. But as I understand it we
    only put one new one online. Is that right?
        Secretary Sebelius. We cut the ribbon in a plant in North
    Carolina just this year.
        Senator Harkin. Yes, that's right.
        Secretary Sebelius. And there is planning underway for the
    second plant.
        Senator Harkin. And that's going to be on track, on time?
    We have the funds for that?
        Secretary Sebelius. I think you have the funds for one
    additional plant the way the funding looks now instead of I
    think it was anticipated 5 or 6 years ago that the funds were
    being set aside for four plants.
        Senator Harkin. Well.
        Secretary Sebelius. And the cost of the North Carolina
    plant turns out that it exceeded what was estimated to be a
    number of years ago.
        Senator Harkin. Well, Madam Secretary, again, one of the
    problems for having these kinds of plants is the question, what
    do they do every year? I mean, if you don't have something
    that's confronting you, how do they keep viable? That's been
    the big problem with vaccine production.
        That's why I suggested, modestly, a year or two ago that
    perhaps what we ought to do on the Federal level is provide a
    free flu shot to every person in the country every year. Oh, I
    forget what the cost came in on that. And there was a cost to
    it.
        But then you balance it against how many people get sick
    just from annual flu, and are hospitalized, and the people that
    die from the flu--and you add that cost. Then we could see if
    you can really do great outreach programs with a free flu shot.
        First of all you keep these plants going because they have
    to meet the demand every year and if we have a pandemic that
    has a different strain, they can shift to that immediately.
        Second, you build up the infrastructure. If you do have a
    pandemic that is hitting us, one of the big problems is just
    getting it out through shopping centers and churches and
    schools and wherever, drug stores and every other place. And if
    you do that on an annual basis then you build up a really good
    infrastructure that's ongoing. And I think you also will build
    up more of a public support for these vaccinations.
        A lot of people don't get flu shots because, well, why? I
    don't know. They don't think they work or they've heard they
    shouldn't get them. They're afraid of getting them, that type
    of thing. And there are a lot of people in this country who are
    allergic to eggs who cannot get these shots because of the egg-
    based production.
        Secretary Sebelius. Right.
        Senator Harkin. I haven't revisited that for some time, but
    again thinking about having a couple of plants that are cell
    based. How do we keep them energized? How do we keep--and we
    can't just leave them set there waiting for the next pandemic
    to come.
        So I would be interested in discussing that with you later
    on.
        Secretary Sebelius. Well I think that would be very
    helpful.
        Dr. Nikki Lurie, who is the Assistant Secretary for
    Preparedness and Response, has been charged with this whole
    countermeasures review. And certainly one of the issues is how
    we prepare for things we don't even know are coming. What sort
    of stockpile do we need against anthrax or unknown viruses that
    may head our way? What's the market for that? So we would love
    to continue that conversation with you.
        I think one of the lessons learned is the kind of
    distribution system that you just mentioned. This year, as you
    know, the H1N1 virus had a much younger target population. So
    we were trying to encourage vaccination of people who typically
    do not get a seasonal flu shot. They're too young or they
    typically don't get the flu.
        We've had an estimated 72 to 81 million people vaccinated,
    using an estimated 81 to 91 million doses, and people are still
    being vaccinated. And we used a lot of nontraditional sources,
    school-based clinics which hadn't been used for years and
    turned out to be very successful with kids. A lot of outreach
    with faith based groups. We went from a 40,000 site
    distribution system for the children's vaccines to 150,000
    sites for H1N1 vaccine
        And so we have a more robust distribution system, a more
    robust outreach system than has been in place, I would suggest,
    in a very long time in America. And that's, I think, very good
    news for whatever comes at us next.
        Senator Harkin. Well, I think we have to keep that----
        Secretary Sebelius. Right.
        Senator Harkin. Activated, some way.
        Secretary Sebelius. Yes.
        Senator Harkin. And that is what I'm concerned about. We've
    done that. But now it's faded out. And we may not do it next
    year. Then a couple years go by. And we may have to really gen
    it up again. That's why I focus on the annual flu.
        Secretary Sebelius. Well with 36,000 people a year dying
    from flu and 200,000 hospitalized--that's our annual flu data--
    and that's pretty serious.

                     COMMUNITIES PUTTING PREVENTION TO WORK

        Senator Harkin. That's pretty serious. And it costs a lot
    of money.
        But I did have one more question. And not to make too far a
    leap from vaccinations to prevention, but this subcommittee put
    $1 billion in the stimulus bill for prevention activities at
    HHS.
        As you mentioned in your statement the cornerstone of that
    is a $373 million grant system to communities which I assume
    will be awarded sometime soon. I don't know when you might
    inform me of that. I understand that States and communities
    that are awarded this ARRA funding will be asked to implement
    their choice of a list of evidence based programs that your
    Department determined are the most likely to be effective.
        I asked my staff. I have not seen that list. If you have
    that could you share that with us? And where did you go to come
    up with this list of evidence-based programs that could be
    effective?
        Secretary Sebelius. Ah, Mr. Chairman, first of all, we'd be
    glad to share those data with you.
        [The information follows:]

                              Mapps Interventions

        Attached is the list of evidence-based MAPPS interventions (Media,
    Access, Point of decision information, Price and, Social support
    services) from which States and communities awarded ARRA funding for
    the ``Communities Putting Prevention to Work'' initiative will choose
    to implement. This list can be found at http://www.cdc.gov/
    chronicdisease/recovery/PDF/MAPPS_Intervention_Table.pdf

         MAPPS Interventions for Communities Putting Prevention to Work

        Five evidence-based MAPPS strategies, when combined, can have a
    profound influence on improving health behaviors by changing community
    environments: Media, Access, Point of decision information, Price, and
    Social support/services. The evidence-based interventions below are
    drawn from the peer-reviewed literature as well as expert syntheses
    from the community guide and other peer-reviewed sources, cited below.
    Communities and states have found these interventions to be successful
    in practice. Awardees are expected to use this list of evidence-based
    strategies to design a comprehensive and robust set of strategies to
    produce the desired outcomes for the initiative.

    ----------------------------------------------------------------------------------------------------------------
                                                   Tobacco                 Nutrition            Physical activity
    ----------------------------------------------------------------------------------------------------------------
    Media................................  Media and advertising    Media and advertising    Promote increased
                                            restrictions             restrictions             physical activity \98\
                                            consistent with          consistent with          \99\ \103\ \106\ \126\
                                            Federal law \11\.        Federal law \53\ \54\    \127\
                                           Hard hitting              \55\ \56\ \57\ \58\     Promote use of public
                                            counteradvertising \12   \59\.                    transit \98\ \99\
                                            \ \13\ \14\ \15\.       Promote healthy food/     \103\ \106\ \126\
                                           Ban brand-name            drink choices \57\       \127\
                                            sponsorship \15\.        \58\ \60\.              Promote active
                                           Ban branded promotional  Counteradvertising for    transportation
                                            items and prizes \16\.   unhealthy choices \61\.  (bicycling and walking
                                                                                              for commuting and
                                                                                              leisure activities)
                                                                                              \98\ \99\ \103\ \106\
                                                                                              \126\ \127\
                                                                                             Counteradvertising for
                                                                                              screen time \98\ \99\
                                                                                              \103\ \106\ \126\
                                                                                              \127\
    Access...............................  Usage bans (i.e., 100    Healthy food/drink       Safe, attractive
                                            percent smoke-free       availability (e.g.,      accessible places for
                                            policies or 100          incentives to food       activity (i.e., access
                                            percent tobacco-free     retailers to locate/     to outdoor recreation
                                            policies) \6\ \7\        offer healthier          facilities, enhance
                                            \102\.                   choices in underserved   bicycling and walking
                                           Usage bans (i.e., 100     areas, healthier         infrastructure, place
                                            percent smoke-free       choices in child care,   schools within
                                            policies or 100          schools, worksites)      residential areas,
                                            percent tobacco-free     \24\ \25\ \26\ \27\      increase access to and
                                            school campuses \5\      \28\ \29\ \30\ \31\      coverage area of
                                            \6\ \7\ \8\ \9\ \10\.    \32\ \33\ \34\ \35\      public transportation,
                                           Zoning restrictions \5\   \36\ \37\ \38\ \78\      mixed-use development,
                                            \6\ \7\.                 \79\ \80\ \81\ \82\      reduce community
                                           Restrict sales (e.g.,     \83\ \91\ \92\ \93\      design that lends to
                                            Internet, sales to       \94\ \95\ \96\ \97\.     increased injuries)
                                            minors, stores/events   Limit unhealthy food/     \136\ \137\ \138\
                                            without tobacco, etc.)   drink availability      City planning, zoning,
                                            \5\ \6\ \7\.             (whole milk, sugar       and transportation
                                           Ban self-service          sweetened beverages,     (e.g., planning to
                                            displays and vending     high-fat snacks) \34\    include the provision
                                            \5\ \6\ \7\.             \39\ \40\ \41\ \42\      of sidewalks, parks,
                                                                     \84\ \85\ \86\ \87\      mixed-use development,
                                                                     \88\.                    reduce community
                                                                    Reduce density of fast    design that lends to
                                                                     food establishments      increased injuries)
                                                                     \32\ \43\.               \99\ \100\ \101\ \102\
                                                                    Eliminate transfat        \105\ \106\
                                                                     through purchasing      Require daily quality
                                                                     actions, labeling        physical education in
                                                                     initiatives,             schools \113\ \114\
                                                                     restaurant standards     \115\ \116\ \117\
                                                                     \44\ \45\ \46\.          \118\ \119\ \120\
                                                                    Reduce sodium through    Require daily physical
                                                                     purchasing actions,      activity in
                                                                     labeling initiatives,    afterschool/child care
                                                                     restaurant standards     settings
                                                                     \47\ \48\ \49\.         Restrict screen time
                                                                    Procurement policies      (afterschool, daycare)
                                                                     and practices \25\       \107\ \108\ \109\
                                                                     \26\ \30\ \31\ \50\      \110\ \111\
                                                                     \51\.
                                                                    Farm to institution,
                                                                     including schools,
                                                                     worksites, hospitals,
                                                                     and other community
                                                                     institutions \50\ \51\
                                                                     \52\.
    Point of purchase/promotion..........  Restrict point of        Signage for healthy vs.  Signage for
                                            purchase advertising     less healthy items       neighborhood
                                            as allowable under       \25\ \26\ \62\ \63\      destinations in
                                            Federal law \17\.        \89\ \90\.               walkable/mixed-use
                                           Product placement \17\.  Product placement and     areas (library, park,
                                                                     attractiveness \25\      shops, etc.) \99\
                                                                     \26\ \62\ \63\ \89\      \100\ \101\ \106\
                                                                     \90\.                    \140\
                                                                    Menu labeling \65\ \66\  Signage for public
                                                                     \67\ \68\.               transportation, bike
                                                                                              lanes/boulevards \99\
                                                                                              \100\ \101\ \106\
                                                                                              \140\
    Price................................  Use evidence-based       Changing relative        Reduced price for park/
                                            pricing strategies to    prices of healthy vs.    facility use \133\
                                            discourage tobacco use   unhealthy items (e.g.,   \134\ \135\
                                            \1\ \2\ \3\.             through bulk purchase/  Incentives for active
                                           Ban free samples and      procurement/             transit \134\ \135\
                                            price discounts \4\.     competitive pricing)    Subsidized memberships
                                                                     \22\ \23\ \24\ \25\      to recreational
                                                                     \26\ \75\ \76\ \77\.     facilities \99\ \100\
                                                                                              \110\ \111\
    Social support and services..........  Quitline and other       Support breastfeeding    Safe routes to school
                                            cessation services       through policy change    \104\ \112\ \128\
                                            \18\ \19\ \20\.          and maternity care       \129\ \130\ \131\
                                                                     \69\ \70\ \71\ \72\      \132\
                                                                     \73\ \74\.              Workplace, faith, park,
                                                                                              neighborhood activity
                                                                                              groups (e.g., walking,
                                                                                              hiking, biking, etc.)
                                                                                              \99\ \100\ \105\ \106\
    ----------------------------------------------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. Reducing tobacco use: a report of the Surgeon General. Atlanta,
      GA: U.S. Department of Health and Human Services, CDC; 2000
    \2\ Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National
      Academies Press; 2007.
    \3\ Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention
      and control. Am J Prev. Med., 2001;20(2 Suppl 1):1-87.
    \4\ Loomis BR, Farrelly MC, Mann NH. The Association of retail promotions for cigarettes with the Master
      Settlement Agreement, tobacco control programmes and cigarette excise taxes. Tob. Control 2006; 15;458-63.
    \5\ Centers for Disease Control and Prevention. Reducing tobacco use: a report of the Surgeon General. Atlanta,
      GA: U.S. Department of Health and Human Services; 2000
    \6\ Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National
      Academies Press; 2007.
    \7\ Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention
      and control. Am J Prev. Med.2001;20(2 Suppl 1):1-87.
    \8\ Pentz MA. The power of policy: the relationship of smoking policy to adolescent smoking. American journal of
      public health 1989;79(7):857-62.
    \9\ Wakefield MA. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking:
      cross sectional study. BMJ2000;321(7257):333-7.
    \10\ Kumar R. School tobacco control policies related to students' smoking and attitudes toward smoking:
      national survey results, 1999-2000. Health education & behavior 2005;32(6):780-94.
    \11\ National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control
      Monograph, No. 19; 2008.
    \12\ Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention
      and control. Am J Prev. Med., 2001;20(2 Suppl 1):1-87.
    \13\ National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control
      Monograph, No. 19; 2008.
    \14\ Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National
      Academies Press; 2007.
    \15\ National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control
      Monograph, No. 19; 2008.
    \16\ National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control
      Monograph, No. 19; 2008.
    \17\ National Cancer Institute. The role of the media in promoting and reducing tobacco use. Tobacco Control
      Monograph, No. 19; 2008.
    \18\ Fiore MC, Jaen CR, Baker, TB, et al. Treating tobacco use and dependence: 2008 Update. Quick Reference
      Guide for Clinicians. Public Health Service; 2008.
    \19\ Task Force on Community Preventive Services. Guide to community preventive services: tobacco use prevention
      and control. Am J Prev. Med., 2001;20(2 Suppl 1):1--87.
    \20\ Institute of Medicine. Ending the tobacco problem: a blueprint for the nation. Washington, DC: The National
      Academies Press; 2007.
    \21\ Dietary Guidelines for Americans, 2005. U.S. Department of Health and Human Services and U.S. Department of
      Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing
      Office, January 2005. Foods Encouraged, Available at: http://www.health.gov/DietarvGuidelines/dga2005/document/
      html/chapter5.htm
    \22\ French, S.A., M. Story, and R.W. Jeffery, Environmental influences on eating and physical activity. Annu
      Rev Public Health, 2001. 22: p. 309-35.
    \23\ French SA, Wechsler H. School-based research and initiatives: fruit and vegetable environment, policy, and
      pricing workshop. Prev. Med., 2004 Sep;39 Suppl 2:S101-7.
    \24\ Ayala G. et al., 2009--Evaluation of the Healthy Tienda project. The Public Health Effects of Food Deserts.
      Workshop Summary. Institute of Medicine and National Research Council, p. 49-51. http://www.iom.edu/
      Obiect.File/Master/62/082/Session%204%20920%20am%20Ayala.pdf.
    \25\ Glanz K, Yaroch AL. Strategies for increasing fruit and vegetable intake in grocery stores and communities:
      policy, pricing, and environmental change. Prev Med., 2004 Sep;39 Suppl 2:S75-80. Review.
    \26\ Nonas C, 2009. Health Bucks in New York City. The Public Health Effects of Food Deserts. Workshop Summary.
      Institute of Medicine and National Research Council, p 59-60. Available at http://www.iom.cdu/CMS/3788/59640/
      62040/62078.aspx
    \27\ Bodor, J. N., Rose, D., Farley, T. A., Swaim, C., & Scott, S. K. (2007). Neighbourhood fruit and vegetable
      availability and consumption: the role of small food stores in an urban environment. Public Health Nutrition.
    \28\ Gittelsohn J, Ethelbah M. Evaluation of the White Mountain and San Carlos Apache Healthy Stores Program, a
      multi-component intervention that included stocking healthier food items. Available at http://
      www.farmfoundation.org/news/articlefiles/450-Gittelsohn.pdf).
    \29\ Morland K, Diez Roux AV, Wing S. Am J Prev. Med., 2006 Apr,30(4):333-9 Supermarkets, other food stores, and
      obesity: the atherosclerosis risk in communities study.
    \30\ Larson, N., Story, M., & Nelson, M. (2009). Neighborhood Environments Disparities in Access to Healthy
      Foods in the U. S. American Journal of Preventive Medicine. 36(1):74-81.
    \31\ Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating healthy food and eating environments: policy
      and environmental approaches. Annu Rev Public Health. 2008;29:253-72.
    \32\ Moore, L.V., et al., Associations of the local food environment with diet quality--a comparison of
      assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis. Am
      J Epidemiol, 2008. 167(8): p. 917-24.
    \33\ Ward, D. S., Benjamin, S. E., Ammerman, A. S., Ball, S. C., Neelon, B. H., & Bangdiwala, S. I. (2008).
      Nutrition and physical activity in child care: results from an environmental intervention. Am J Prev. Med.,
      35(4), 352-356. Epub 2008.
    \34\ IOM (2007). Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth Committee on
      Nutrition Standards for Foods in Schools. Washington, D.C., The National Academies Press.
    \35\ Ritenbaugh C, Tuefel-Shone N, et al. A lifestyle intervention improves plasma insulin levels among Native
      American high school youth. Prev. Med., 2003;36:309-319.
    \36\ Jaime, P.C. and K. Lock, Do school based food and nutrition policies improve diet and reduce obesity? Prev
      Med., 2009.48(1): p. 45-53.
    \37\ Sorensen, G., Linnan, L., & Hunt, M. K. (2004). Worksite-based research and initiatives to increase fruit
      and vegetable consumption. Prev. Med., 39 Suppl 2, S94-100.
    \38\ The Community Guide to Preventive Services. Obesity prevention through worksite programs. Available at
      http://www.thecommunitvguide.org/obesity/workprograms.html
    \39\ Schwartz, M. B., Novak, S. A., & Fiore, S. S. (2009). The Impact of Removing Snacks of Low Nutritional
      Value From Middle Schools. Health Educ Behav, 5, 5.
    \40\ Kubik, M.Y., et al., The association of the school food environment with dietary behaviors of young
      adolescents. Am J Public Health, 2003. 93(7): p. 1168-73.
    \41\ Cullen, K.W. and I. Zakeri, Fruits, vegetables, milk, and sweetened beverages consumption and access to a
      la carte/snack bar meals at school. Am J Public Health, 2004. 94(3): p. 463-7.
    \42\ Templeton, S.B., M.A. Marlette, and M. Panemangalore, Competitive foods increase the intake of energy and
      decrease the intake of certain nutrients by adolescents consuming school lunch. J Am Diet Assoc, 2005. 105(2):
      p. 215-20.
    \43\ Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control of alcohol, tobacco, firearms, and
      fast food restaurants. Am J Pub Health. 2003;93(9):1404-1408.
    \44\ Mozaffarian D. Katan MB. Ascherio A. Stampfer MJ. Willett WC. Trans Fatty Acids and Cardiovascular Disease.
      New England Journal of Medicine. April 13, 2006. 354;15:1601-13.
    \45\ Panel on Macronutrients, Institute of Medicine. Letter report on dietary reference intakes for trans fatty
      acids drawn from the Report on dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids,
      cholesterol, protein, and amino acids. Washington, DC 2003.
    \46\ Trans Fat Regulation: NYC Department of Health and Mental Hygiene--Board of Health Approves Regulation to
      Phase Out Artificial Trans Fat. Available at: http://www.nyc.gov/html/doh/html/cardio/cardio-transfat-
      healthcode.shtml; How to Comply: What Restaurants, Caterers, Food-Vending Units, and Others Need to Know''
      Accessed June 24, 2009 http://www.nvc.gov/html/doh/downloads/ndf/cardio/cardio-transfat-bro.pdf
    \47\ Sacks, FM et al. (2001) Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to
      Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. New England Journal of Medicine
      344(1):3-10.
    \48\ City Purchasing Standards: New York City executive order for formal nutrition standards for all food
      purchased or served by New York City agencies including sodium. Available at: http://www.nyc.gov/html/doh/
      downloads/pdf/cardio/cardio-food-standards.pdf
    \49\ New York City, Advocacy for External Efforts: Initiative to develop a voluntary partnership with industry
      leaders to reduce the level of sodium in processed and prepared foods nationwide. Available at: http://
      www.nyc.gov/litml/doh/html/cardio/cardio-salt-initiative.shtml
    \50\ Joshi, A., & Azuma, A. (2008). Do Farm-to-School Programs Make a Difference? Findings and Future Research
      Needs. Journal of Hunger & Environmental Nutrition, 3, 2-3.
    \51\ Zudrow D (2005) Food Security Begins at Home: Creating Community Food Coalitions in the South. Southern
      Sustainable Agriculture Working Group, pp 45-67, Available at: http://www.ssawg.org/cfs-handbook.html
    \52\ Texas, Farm to Work program. Farm to Work Initiative of the Texas State Health Service provides a Farm to
      Work Toolkit. Available at http://www.texasbringinghealthyback.org/ and http://www.dshs.state.tx.us/obesitv/
      pdf/F2WToolkit1008.pdf
    \53\ The Guide to Community Preventive Services--Obesity Prevention: Interventions to Reduce Screen Time http://
      www.thecommunityguide.org/obesity/screentime/index.html
    \54\ Story M. French S. Food Advertising and Marketing Directed at Children and Adolescents in the US. Int J
      Behav Nutr Phys Act. 2004 Feb 10;1(1):3.
    \55\ Chou SY, Rashad I, Grossman M. Fast-Food Restaurant Advertising on Television and Its Influence on
      Childhood Obesity. The Journal of Law and Economics, 2008:51; p 599-618
    \56\ Coon KA, Tucker KL: Television and children's consumption patterns. A review of the literature. Minerva
      Pediatr 2002, 54:423-436.
    \57\ WHO. 2004. Global Strategy on Diet, Physical Activity and Health. WHA 57.17. Geneva: WHO. Available at
      http://apps.who.int/gb/ebwha/pdf files/WHA57/A57_R17-en.ndf
    \58\ Norwegian ministry of Children and Family Affairs, 2005. Norway enacted a ban on TV advertisements to
      children ages 12 years and younger in 1992. Available at http://www.regieringen.notenklep/b1d/Documents/
      Rcports-and-plans/Plans/2003-2/The-Norwegian-action-plan-to-reduce-comm.html?id-462256
    \59\ Kwate, NOA. Take one down, pass it around, 98 alcohol ads on the wall: outdoor advertising in New York
      City's Black neighbourhoods. International Journal of Epidemiology. 2007; 36 (5): 988-990.
    \60\ Evidence of impact of advertising on food and beverage purchase requests of 2-11 year olds and usual
      dietary intake of 2-5 year olds: IOM (2006), Committee on Food Marketing and the Diets of Children and Youth.
      Food Marketing to Children and Youth: Threat or Opportunity? Washington, D.C., National Academies Press.
    \61\ Dixon HG, Scully ML, Wakefield MA, White VM, Crawford DA.The effects of television advertisements for junk
      food versus nutritious food on children's food attitudes and preferences. Soc Sci Med. 2007 Oct;65(7):1311-23.
    \62\ Seymour JD, Yaroch AL, Serdula M, Blanck HM, Khan LK. Impact of nutrition environmental interventions on
      point-of-purchase behavior in adults: a review. Prev. Med., 2004 Sep;39 Suppl 2:S108-36. Review.
    \63\ Glanz K, Hoelscher D. Increasing fruit and vegetable intake by changing environments, policy and pricing:
      restaurant-based research, strategies, and recommendations. Prev. Med., 2004 Sep;39 Suppl 2:S88-93.
    \64\ Curhan, R.C., The effects of merchandising and temporary promotional activities on the sales of fresh fruit
      and vegetables in supermarket. Journal of Marketing Research 1974. 11: p. 286-94.
    \65\ Bassett, M.T., et al., Purchasing behavior and calorie information at fast-food chains in New York City,
      2007. Am J Public Health, 2008. 98(8): p. 1457-9.
    \66\ Simon, Jarosz, Kuo & Fielding. Menu Labeling as a Potential Strategy for Combating the Obesity Epidemic: A
      Health Impact Assessment. Los Angeles, CA: Los Angeles County Dept of Public Health; 2008
    \67\ Burton S and Creyer EH. ``What Consumers Don't Know Can Hurt Them: Consumer Evaluations and Disease Risk
      Perceptions of Restaurant Menu Items.'' Journal of Consumer Affairs, 38(1): 121-45, 2004.
    \68\ Kozup KC, Creyer EH and Burton S. ``Making Healthful Food Choices: The Influence of Health Claims and
      Nutrition Information on Consumers' Evaluations of Packaged Food Products and Restaurant Menu items.'' Journal
      of Marketing, 67(2): 19-34,2003.
    \69\ Philipp BL et al. 2001. Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US
      Hospital Setting. Pediatrics 108(3):677-681.
    \70\ DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of Maternity-Care Practices on Breastfeeding. Pediatrics
      2008 October I;122(Supplement_2):S43-S49.
    \71\ Baby-Friendly USA. Implementing the UNICEF/WHO Baby Friendly Hospital Initiative in the U.S.; Available at:
      http://www.babyfriendlyusa.org/eng/index.html Accessed June 24,2009.
    \72\ Cohen R, Mrtek MB. The impact of two corporate lactation programs on the incidence and duration of
      breastfeeding by employed mothers. American Journal of Health Promotion 1994;8(6):436-41.
    \73\ Fein SB, Mandal B, Roe BE. Success of Strategies for Combining Employment and Breastfeeding. Pediatrics
      2008 October 1;122(Supplement_2):S56-562.
    \74\ Health Resources and Services Administration. The Business Case for Breastfeeding Toolkit. HRSA 2008;
      Available at: http://ask.hrsa.govidetail.cfm?PublD=MCH00254&recommended=1 Accessed June 2, 2009.
    \75\ French, S.A., Story, M., Jefferey, R.W., Snyder, P., Marla, E., Sidebottom, A., & Murray, D. (1997).
      Pricing strategy to promote fruit and vegetable purchase in high school cafeterias. J Am Diet Assoc, 97(9):
      1008-1010.
    \76\ French, S.A., Jefferey, R.W., Story, M., Breitlow, K.K., Baxter, J.S., Hannan, P., & Snyder, M.P. (2001).
      Pricing and promotion effects on low-fat vending snack purchases: The CHIPS study. Am J Public Health, 91(1):
      112-117.
    \77\ Hannan, P., French, S.A., Story, M., & Fulkerson, J.A. (2002). A pricing strategy to promote sales of lower
      fat foods in high school cafeterias: Acceptability and sensitivity analysis. Am J Hlth Prom, 17(1): I-6.
    \78\ Cullen, K.W., Hartstein, J., Reynolds, K.D., Vu, M., Resnicow, K., Greene, N., et al., 2007. Improving the
      school food environment: results from a pilot study in middle schools. J. Am. Diet Assoc. 107 (3), 484-489.
    \79\ Lytle, L.A., Kubik, M.Y., Perry, C., Story, M., Birnbaum, A.S., Murray, D.M., 2006. Influencing healthful
      food choices in school and home environments: results from the TEENS study. Prev. Med., 43 (1), 8-13.
    \80\ Perry, C.L., Bishop, D.B., Taylor, G.L., Davis, M., Story, M., Gray, C., et al., 2004. A randomized school
      trial of environmental strategies to encourage fruit and vegetable consumption among children. Health Educ.
      Behay. 31 (1), 65-76.
    \81\ Sahota, P., Rudolf, M.C., Dixey, R., Hill, A.J., Barth, J.H., Cade, J., 2001. Evaluation of implementation
      and effect of primary school based intervention to reduce risk factors for obesity. BMJ 323 (7320), 1027-1029.
    \82\ Sahota, P., Rudolf, M.C., Dixey, R., Hill, A.J., Barth, J.H., Cade, J., 2001. Randomised controlled trial
      of primary school based intervention to reduce risk factors for obesity. BMJ 323 (7320), 1029-1032.
    \83\ Muckelbauer R, Libuda L, Clausen K, Toschke AM, Reinehr T, Kersting M. Promotion and provision of drinking
      water in schools for overweight prevention: Randomized, controlled cluster trial. Pediatrics 2009;123;e661-
      e667
    \84\ Cullen, K.W., Hartstein, J., Reynolds, K.D., Vu, M., Resnicow, K., Greene, N., et al., 2007. Improving the
      school food environment: results from a pilot study in middle schools. J. Am. Diet Assoc. 107 (3), 484-489.
    \85\ Cullen, K.W.,Watson, K., Zakeri, I., Ralston, K., 2006. Exploring changes in middle-school student lunch
      consumption after local school food service policy modifications. Public Health Nutr. 9 (6), 814-820.
    \86\ Cullen, K.W., Watson, K. 2009. The Impact of the Texas Public School Nutrition Policy on Student Food
      Selection and Sales in Texas. Am J Public Health. 2009 Apr;99(4):706-12
    \87\ Kubik M, Lytle L, Hannan P, Perry C, Story M. The association of the school food environment with dietary
      behaviors of young adolescents. Am J Public Health 2003;93:1168-73.
    \88\ Stone, E.J., Osganian, S.K., McKinlay, S.M., Wu, M.C., Webber, L.S., Luepker, R.V., et al., 1996.
      Operational design and quality control in the CATCH multicenter trial. Prev.
    \89\ French, S. A., Jeffery, R. W., Story, M., Breitlow, K. K., Baxter, J. S., Hannan, P. & Snyder, M. P. (2001)
      Pricing and promotion effects on low-fat vending snack purchases: The CHIPS study. Am. J. Public Health 91:112-
      117.
    \90\ French SA, Story M, Fulkerson JA, Hannan P. An Environmental Intervention to Promote Lower-Fat Food Choices
      in Secondary Schools: Outcomes of the TACOS Study. Am J Public Health 2004;94:1507-12
    \91\ Institute of Medicine. Local Government Actions to Prevent Childhood Obesity. Washington, DC: The National
      Academies Press; 2009.
    \92\ Centers for Disease Control and Prevention. Recommended Community Strategies and Measurements to Prevent
      Obesity in the United States. MMWR 2009; 58(No. RR-07): 1-26.
    \93\ Ed Bolen et al., Neighborhood Groceries: New Access to Healthy Food in Low-Income Communities, (San
      Francisco, CA: California Food Policy Advocates, 2003).
    \94\ PolicyLink: Equitable Development Toolkit: Healthy Food Retailing provides an online tool that focuses on
      increasing access to retail outlets that sell nutritious, affordable food in low-income communities of color.
      http://www.policylink.org/EDTK/HealthyFoodRetailing
    \95\ Gittelsohn, J., et al., Process Evaluation of Baltimore Healthy Stores: A Pilot Health Intervention Program
      With Supermarkets and Corner Stores in Baltimore City. Health Promot Pract, 2009.
    \96\ Flournoy R and Treuhaft S (2005). Healthy food, healthy communities: improving access and opportunities
      through food retailing. Oakland, CA: PolicyLink.
    \97\ Bitler, M., and S. J. Haider. An Economic View of Food Deserts in the United States. Research Conference on
      Understanding the Economic Concepts and Characteristics of Food Access. Washington, DC: USDA, Economic
      Research Service and University of Michigan National Poverty Center, 2009.
    \98\ U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. Available at:
      http://www.health.gov/PAGuidelines/
    \99\ The Guide to Community Preventive Services: What works to Promote Health?. Oxford University Press, 2005,
      pp 80-113.
    \100\ Kahn, E.B., Ramsey, L.T., Brownson, R.C., Health, G.W., Howze, E.H., Powell, K.E. et al. 2002. The
      effectiveness of interventions to increase physical activity. A systematic review by the U.S. Task Force on
      Community Preventive Services. American Journal of Preventive Medicine 22, S73-I 02.
    \101\ Heath GW, Brownson RC, Kruger J, et al. The effectiveness of urban design and land use and transport
      policies and practices to increase physical activity: a systematic review. J Phys Act Health. 2006;3'suppl
      1):S55-S76.
    \102\ Hoehner CM, Soares J, Parra DP, Ribeiro IC, Joshu C, Pratt M et al. 2008. Systematic review of physical
      activity interventions in Latin America. Am J Prev. Med., 34(3), 224-233
    \103\ Roux L, Pratt M, Tengs TO, Yanagawa T, Yore M, et al., 2008. Cost Effectiveness of Community-based
      Physical Activity Interventions. Am J Prev. Med., 35(6), 578-588
    \104\ Active Living Research Brief. Walking and biking to school, physical activity and health outcomes. May
      2009
    \105\ Ramsey LT, Brownson RC. Increasing physical activity. Am J Prev. Med., 2002 (4S); 73-107
    \106\ Centers for Disease Control and Prevention. Planning, implementing and evaluating interventions. Available
      at: http://www.cdc.gov/inccdphp/dnpa/physical/health_professionals/interventions/index.htm
    \107\ The Guide to Community Preventive Services--Obesity Prevention: Interventions to Reduce Screen Time. http:/
      /www.thecommunityguide.org/obesity/screentime/index.html
    \108\ New York City Amendments to the NYC Health Code (established limits on passive, sedentary TV viewing in
      group childcare services to 60 minutes or less per day. http://www.frac.org/pdf/
      nyc_cacfp_childcare_nutrphysactlaw.pdf
    \109\ Delaware Child Care Policy to Improve Children's Health: regulatory changes through the Office of Child
      Care Licensing for all childcare in DE (center-based, family and after-school) that limit sedentary and media
      exposure to a maximum of 1 hour per day for children >2 years. http://www.nemours.org/department/nhps/policy-
      leader/child-care.html
    \110\ Benjamin SE, Cradock A Walker EM, Slining M, Gillman MW. Obesity prevention in child care: a review of
      U.S. state regulations. BMC Public Health. 2008;8:188.
    \111\ Kaphingst LM, Story M. Child care as an untapped setting for obesity prevention: State child care
      licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in
      the United States. Preventing Chronic Disease. 2009;6:1.
    \112\ Centers for Disease Control and Prevention. Kids Walk to School. Available at: http://www.cdc.gov/inccdphp/
      dnpa/kidswalk/
    \113\ Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE. The effectiveness of interventions to
      increase physical activity: a systematic review. Am J Prev. Med., 2002; 22(4S): 73-107.
    \114\ McKenzie TL, Nader PL, Strikmiller PK, Yang M, Stone EJ, Perry CL, et al. School physical education:
      effect of the Child and Adolescent Trial for Cardiovascular Health. Prev. Med. 1996 25:423-431.
    \115\ Pangrazi RP, Beighle A, Vehige T, Vack C. Impact of Promoting Lifestyle Activity for Youth (PLAY) on
      children's physical activity. J Sch Health 73(8): 317-321.
    \116\ Pate RR, Ward DS, Saunders RP, Felton G, Dishman RK, Dowda M. Promotion of physical activity among high
      school girls: a randomized controlled trial. Am J Public Health 2005; 95(9): 1582-1587.
    \117\ Harrell JS, McMurray RG, Bangdiwala SI, Frauman AC, Gansky SA, Bradley CB. Effects of a school-based
      intervention to reduce cardiovascular disease risk factors in elementary-school children: The Cardiovascular
      Health in Children (CHIC Study. J Pediatr 1996; 128:797-805.
    \118\ Reed KE, Warburton DER, Macdonald HM, Naylor P.1, McKay HA. Action schools! BC: a school-based physical
      activity intervention designed to decrease cardiovascular risk factors in children. Prev. Med., 2008; 46:525-
      531.
    \119\ Webber LS, Catellier DJ, Lytle LA, Murray DM, Pratt CA, Young DR, et al. Promoting physical activity in
      middle school girls: Trial of Activity for Adolescent Girls. Am J Prev. Med., 2008; 34(3): 173-184.
    \120\ Manios Y, Moschandreas J, Hatzis C, Kafatos A. Evaluation of a health and nutrition education program in
      primary school children of Crete over a three-year period. Prev. Med., 1999; 28:149-159.
    \121\ Sallis JF, McKenzie TL, Conway TL, Elder JP, Prochaska JJ, Brown M et al. Environmental interventions for
      eating and physical activity: a randomized controlled trial in middle schools. Am J Prev. Med., 2003;24:209-
      17.
    \122\ Kelder S, Hoelscher DM, Barroso CS, Walker JL, Cribb P, Shaohua H. The CATCH Kids Club: a pilot after-
      school study for improving elementary students' nutrition and physical activity. Public Health Nutrition 2005;
      8(2): 133-140.
    \123\ Story M, Sherwood NE, Himes JH, Davis M, Jacobs DR, et al. An after-school obesity prevention program for
      African American girls: the Minnesota GEMS pilot study. Ethn Dis 2003; 13(1 suppl 1): S54 64.
    \124\ Yin, et al. Medical College of Georgia Fitkid Project. Evaluation & the Health Professions 2005; 67-89.
    \125\ Kien LC & Chiodo AR. Physical activity in middle school-aged children participating in a school-based
      recreation program. Arch Pediatr Adolesc Med 2003; 157:811-815.
    \126\ Huhman M, Potter LD, Wong FL, Banspach SW, Duke JC, Heitzler CD. Effects of a mass media campaign to
      increase physical activity among children: year 1 results of the VERB campaign. Pediatrics 2005;116:e277-3284.
    \127\ Huhman M, Bauman A, Bowles HR. Initial outcomes of the VERB campaign: tweens' awareness and understanding
      of campaign messages. J Prev. Med., 2008; 34(6S):S241-S248.
    \128\ Cooper AR, Page AS, Foster U, Qahwaji D. Commuting to school: are children who walk more physically
      active? Am J Prev. Med., 2003;25:273-6.
    \129\ Cooper AR. Physical activity levels of children who walk, cycle, or are driven to school. Am J Prev. Med.,
      2005;29:179-84.
    \130\ Tudor-Locke C, Neff LJ, Ainsworth BE, Addy CL, Popkin BM. Omission of active commuting to school and the
      prevalence of children's health-related physical activity levels: the Russian Longitudinal Monitoring Study.
      Child Care Health Dev 2002;28:507-12.
    \131\ Alexander LM, lnchley J, Todd J, Currie D, Cooper AR, Currie C. The broader impact of walking to school
      among adolescents: seven day accelerometry based study. BMJ 2005;331:1061-2.
    \132\ Sirard J, Riner WJ, McIver K, Pate R. Physical activity and active commuting to elementary school. Med Sci
      Sports Exerc 2005;37:2062-9.
    \133\ Managed-Medicare health club benefit and reduced healthcare costs among older adults. Nguyen HQ, Ackerman
      RT, Maciejewski M, Berke E, Patrick M. Williams B, LoGerfo JP, Prev. Chronic Disease, 2008 Jan 5(1) A14. Epub
      2007 Dec 15.
    \134\ Economic interventions to promote physical activity. Application of the SLOTH model. Pratt, M, Macera CA,
      Sallis JF, O'Donnell M, Frank LD. Am J Prev. Med 2004, 27(S 1)
    \135\ The economics of physical activity: Societal trends and rationales for interventions. Strum R, Am J Prev.
      Med., 2004, 27 (SI).
    \136\ The built environment, neighborhood crime and constrained physical activity: An exploration of
      inconsistent findings. Foster, S, Giles-Corti B. Prev. Med., 2008, 47 (3) pp 241-251.
    \137\ Unsafe to play? Neighborhood disorder and lack of safety predict reduced physical activity among urban
      children and adolescents. Molnar, S, Gortmaker, S, Bull F, Buka SL. Am J Health Prom 2004, 18(5) pp 378-386.
    \138\ Parents' perceptions of neighborhood safety and children's physical activity. Weir, L, Etelson D, Brand D.
      Prev. Med 2006, 43(3) pp 212-217.
    \139\ Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations.
      Am J Prev. Med., 2005; 29(4):273-80.
    \140\ MMWR: Morbidity and Mortality Weekly Report. Recommended community strategies and measurements to prevent
      obesity in the United States. Centers for Disease Control and Prevention. July 24, 2009 58(RR07);1-26. http://
      www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm

        Secretary Sebelius. And the community grants I think are
    about to go out the door in the next, I think somewhere in the
    next 2-week period of time the awards will be made. And the
    focus looking at not only the--we had a multidiscipline team,
    scientists from NIH, the surveillance folks from and public
    health folks from CDC, our Office of Public Health and Science,
    all looking at not only what the most serious cost drivers were
    for underlying disease conditions, but also what were effective
    strategies that had been measured and looked at.
        And the two focus areas for the community grants were
    determined to be smoking cessation efforts and efforts aimed at
    obesity as the two drivers for a large number of the chronic
    conditions that cause healthcare spending to rise and cause
    quality of life to go down. So the so-called list looked at
    measures that had existed across States and communities that
    were effective strategies, had been measured, had been proven
    effective. And we would be delighted to share those with you.
        But the community grants were available to either look at
    smoking cessation and/or obesity or both, one or the other or
    both. But those were the two kinds of targets. As opposed to
    spreading them out across the horizon that the focus on those
    two areas.
        And then the hope is, as you know, with the ARRA funding is
    to have kind of measurable results. So at the end of 2 years
    the goal is to have some strategies which really do either
    encourage young people from not smoking in the first place,
    decrease smoking dramatically and/or make a real dent in
    obesity. And then be able to come back and hopefully work with
    members of Congress to take some of those programs to scale.
        If we can find effective ways, effective strategies to deal
    with those two underlying conditions, we can dramatically
    change health outcomes and dramatically lower health costs.
        Senator Harkin. Very good. Thank you, Madam Secretary.
        Senator Cochran. Mr. Chairman.
        I think the Secretary has done a great job in presenting
    the budget request and answering our questions. It's a pleasure
    working with you in helping make sure that what we decide to
    appropriate is in the national interest and serves the public
    interest.
        Senator Harkin. Thank you.

                            WASTE, FRAUD, AND ABUSE

        I just had one other thing that I would bring up and that
    is this waste, fraud and abuse that, you mentioned. I have a
    partial list in front of me. I have an entire list that adds up
    to literally billions of dollars of fines and settlements paid
    by pharmaceutical companies.
        Secretary Sebelius. You bet.
        Senator Harkin. That have been ripping off Medicare and
    Medicaid.
        Secretary Sebelius. Yes, sir.
        Senator Harkin. So a lot of times we think about Medicare
    fraud and abuse, waste, you know you think well, there's
    somebody out there, some person out there that's putting in for
    something that they shouldn't get. Well, what about Pfizer?
    Pfizer just paid $2.3 billion, the largest----
        Secretary Sebelius. The largest----
        Senator Harkin [continuing]. Settlement in United States
    history.
        Secretary Sebelius. Yes.
        Senator Harkin. Now attorneys know that when you settle,
    you settle because you're afraid of what may happen if you
    actually go to court. That's why you settle. They settled $2.3
    billion, $668 million to Medicare, $331 million to Medicaid.
    That was just this year.
        Four other pharmaceutical companies, Mylan Pharmaceuticals,
    AstraZeneca, UDL and Ortho-McNeil, just paid $124 million to
    Medicaid this year. And Ethex was fined $23.4 million. Now all
    of these were done by the Attorney General's Office. And that's
    just this year.
        I can go back 6, 7, 8 years. Attorneys General in the Bush
    administration and others that went after these companies and
    got all these fines and settlements, hundreds of millions of
    big, big dollars. Well, that's good. I applaud the Attorneys
    General for doing that, both the present Attorney General and
    his predecessors.
        But what can we put in place so they don't do that in the
    first place? And I hope that your Department will look at that.
    How was it that these pharmaceutical companies got by with
    this? And some of them got by with it--this didn't just happen
    over a couple of months. I mean they've been doing it for
    years.
        Then all of a sudden someone catches them. The Department
    of Justice asks for them. That takes a long time, couple years.
    And then they finally build a case. They get the evidence. And
    then they either get fined or they get settled.
        So I hope and this is just--I don't know if you want to
    respond to this or not, but I would really be looking forward
    to working with you on how you can build systems up that just
    don't allow these kinds of big bucks to be taken out of the
    system over long periods of time.
        Secretary Sebelius. Well, I couldn't agree with you more,
    Mr. Chairman. I think that in the case of the Pfizer
    settlement, it was a situation where they were improperly
    marketing and prescribing a drug specifically in violation of
    the authority that they had been given by the FDA. And it not
    only was a case of, you know, driving profits for their
    company, but also putting patients in jeopardy. I don't think
    there's any question that patients were being inappropriately
    prescribed a drug that they knew was not going to work for the
    situation that they had.
        So it's kind of a double concern. It not only involved
    dollars, but it involved patient safety. And I can guarantee
    that the new FDA leadership takes that very seriously, and has
    enhanced the efforts to make sure that off market products are
    not allowed and that we follow up much more vigorously. But
    also I think, again, having a settlement like this puts a
    number of manufacturers on notice that we are taking this very
    seriously. And intend to make sure that they are appropriately
    using the authority that they've been given.
        Senator Harkin. Is there a good working relationship
    between you and FDA on issues like this?
        Secretary Sebelius. Oh, absolutely, absolutely. And the
    drug safety and the drug protocol is something I think they
    take very seriously. And we're very involved in this effort as
    is our Inspector General. I mean, this was again, a
    collaborative effort.
        You're right. It took a number of years. The good news is
    that money went right back in to both the Medicare Trust Fund
    and the Medicaid funds for States. States got a share of those
    returns. And I think it helps make those more solvent for the
    future.
        Senator Harkin. Madam Secretary, thank you very much.
    That's very reassuring.
        Senator Cochran. Thank you, Mr. Chairman. I join you in
    thanking the Secretary for your cooperation with our
    subcommittee. We look forward to working with you as we go
    through this fiscal year. Thank you very much.
        Secretary Sebelius. Thank you, Senator.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. Thank you, Senator Cochran.
        Thank you, Madam Secretary.
        If there is nothing else that you would like us to
    consider----
        Secretary Sebelius. Mr. Chairman, we look forward to
    working with you. Thank you very much.
        [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

                               PROJECT BIOSHIELD

        Question. Madam Secretary, I would like to commend your the
    Department of Health and Human Services (HHS) for including in its most
    recent broad agency announcement for medical countermeasure development
    a clear articulation of the Department's scenario-based medical
    countermeasure requirements for anthrax and smallpox. For several
    years, industry has been concerned regarding the lack of clearly
    articulated evidence-based requirements. This public articulation of
    the requirements is very welcome; however, it raises important concerns
    about the resources that remain in the Project BioShield Special
    Reserve Fund (SRF). Are the remaining SRF funds sufficient to procure
    technologically appropriate countermeasures for the identified
    requirements?
        Answer. The Assistant Secretary for Preparedness and Response
    (ASPR) has plans for the $2.4 billion remaining in the SRF, including
    anticipated procurements of countermeasures for the threat areas of
    anthrax, botulism, smallpox, and acute radiation syndrome illnesses.
    Under Biomedical Advanced Development Authority (BARDA) advanced
    research and development program there are numerous medical
    countermeasures under development. Some of these programs may mature
    enough before the end of fiscal year 2013 to become eligible for late-
    stage development and procurement under Project BioShield. These
    medical countermeasures address threat areas such as anthrax, smallpox,
    botulism, acute radiation syndrome, and chemical agent nerve analysis.
        Question. How does HHS anticipate balancing the needs to continue
    funding advanced development activities with the need to continue
    stockpiling products to meet these stated requirements?
        Answer. In early December, I directed my Department to conduct a
    full review of the public health emergency medical countermeasure
    enterprise, which is the program that ultimately translates the ideas
    from the research bench into approved products that the United States
    can depend upon in the event of naturally occurring emerging diseases,
    pandemic diseases, or threats from chemical, biological, radiological,
    and nuclear (CBRN) agents. The MCM enterprise review is examining how
    policies affect every step of the medical countermeasure development,
    manufacturing, and stockpiling process, finding ways to improve and
    implement necessary changes. The goals of the review are to enhance the
    medical countermeasure development and production process, increase the
    number of promising discoveries going into advanced development, and
    provide more robust and rapid product manufacturing. HHS senior
    leadership with those of other Departments like the Department of
    Defense (DOD) meets regularly to discuss the medical countermeasure
    portfolios for CBRN and flu programs across the Federal Government and
    HHS toward understanding and achieving strategic goals and meeting
    product requirements.
        Question. Does HHS have a long-term strategy for how it plans to
    replenish the SRF or otherwise devote funding to the procurement of
    countermeasures for these identified requirements?
        Answer. HHS has initiated a long-term strategy for development and
    procurement of CBRN medical countermeasures that coordinates with DOD
    quadrennial strategy and planning for medical countermeasures. This
    strategy will be informed by the findings and recommendations of the
    medical countermeasure review that is nearing completion. Initiatives
    resulting from the medical countermeasure review will inform the budget
    process and assist in the balancing of resources for medical
    countermeasures with those of other high-priority initiatives at HHS.

                            MEDICAL COUNTERMEASURES

        Question. Last summer, in the face of the H1N1 pandemic, HHS moved
    with remarkable speed to approve new influenza vaccines and approve
    emergency-use authorization for medical products critical to protecting
    Americans. The entire Department responded to this threat as if it were
    a matter of national security. While the process was not without its
    problems in general it was fast, efficient and remarkably transparent.
    I am concerned that this same sense of urgency is not being applied to
    medical countermeasures being developed to prevent or mitigate the
    threats that have been identified as critical national security
    priorities but have not yet materialized. The intentional release of
    CBRN agents or the detonation of a nuclear device will come with little
    or no warning, we as a Nation must have already developed and
    stockpiled safe and effective countermeasures if we are to respond to
    these types of threats. What measures has HHS taken to ensure the
    efficient and timely review of medical countermeasures for CBRN
    threats?
        Answer. In early December, I directed my Department to conduct a
    full review of the medical countermeasure process from the research
    bench into approved products that the United States can depend upon in
    the event of naturally occurring emerging diseases, pandemic diseases,
    or threats from CBRN agents. This review was initiated, based in part
    by observations of our national response capability at that time for
    the 2009 H1N1 influenza pandemic, and by procurement actions to develop
    an approved next-generation anthrax vaccine under the BioShield
    authorities. The executive leaders within HHS, including those from the
    ASPR, Centers for Disease Control and Prevention (CDC), Food and Drug
    Administration (FDA), and the National Institute of Allergy and
    Infectious Diseases, have worked diligently toward completing a
    comprehensive review of the medical countermeasure enterprise, which
    will be provided to me soon.
        Question. Does BARDA or the NIH provide funding resources to the
    FDA to help offset the cost associated with pre-biologics license
    application (pre-BLA) or pre-new drug application (pre-NDA) regulatory
    activities? Could additional funds improve the ability of FDA to
    providing timely review and responses to companies that are under
    contract with the Federal Government to develop products that the
    national security apparatus of the U.S. Government has identified as
    critical unmet needs?
        Answer. BARDA and the National Institutes of Health (NIH) do not
    provide funding to FDA to help offset the cost associated with pre-BLA
    or pre-NDA regulatory activities. Currently, the administration is
    conducting a comprehensive review of the Public Health Emergency
    Medical Countermeasure Enterprise, including medical countermeasure
    development priorities and resources, which includes FDA's resources to
    robustly engage with partners throughout a product's developmental
    lifecycle. FDA places a top priority on regulatory inquiries and
    submissions from sponsors and U.S. Government partners that are engaged
    in developing products that have been identified as meeting a critical
    need.
        Question. How extensively has the leadership of the FDA and the
    staff responsible for reviewing medical countermeasures been briefed on
    the national security threat assessments for CBRN agents? How many FDA
    employees that are involved in the review of medical countermeasures
    being developed under contract with BARDA and NIH have the appropriate
    security clearances necessary to allow them to receive classified
    briefings?
        Answer. FDA leadership has been briefed and is very aware of the
    national security threat assessments for CBRN agents. FDA leadership is
    briefed by the HHS Office of Security and Strategic Information, and
    FDA has an employee assigned to that Office. In addition, FDA's Office
    of Criminal Investigations, within the Office of Regulatory Affairs,
    works with the intelligence community to obtain information and briefs
    FDA's leadership as needed. Across FDA's three Centers that review
    medical countermeasure products, 106 employees that have been or in the
    future may be involved in medical countermeasure-related reviews have
    received special clearances to review classified documents related to
    product review submissions.

                           EARLY CHILDHOOD EDUCATION

        Question. Madam Secretary, you and Secretary Duncan have been
    working very closely in the area of early childhood education. How do
    you see the collaboration continuing? What lessons has HHS learned
    about approaches to supporting at-risk children and their families that
    can be carried over into K-3 education?
        Answer. Because quality early childhood education spans the ages of
    birth to age 8 and involves the transition of children from early
    childhood programs into our Nation's schools, continued collaboration
    between the two Departments is essential. Secretary Duncan and I have
    been working very closely, and we have a number of joint efforts
    currently underway. We have formed working groups consisting of the
    best minds in both Departments to address the most pressing issues in
    the early childhood field, including creating a more educated, better-
    trained early childhood workforce; better connecting the early
    education and health systems; and improving the way data are collected
    and used to improve early childhood systems at the State level; and
    coordinating Federal research and evaluation efforts in the area of
    early childhood. The two Departments are currently co-hosting listening
    sessions across the country to hear from the foremost experts and early
    childhood practitioners concerning these issues. The Departments
    consult regularly on the early childhood initiatives underway in each
    Department and will continue to collaborate on future initiatives and
    legislation that are vital to the development and education of our
    Nation's youngest children.
        Historically, HHS's approach to supporting the early education of
    at-risk children has been to foster growth in all developmental
    domains. In addition to emphasizing early education domains, such as
    literacy and early math, a strong focus on health, nutrition, and
    social-emotional development, for example, is essential in efforts to
    prepare children for school. This is a vital lesson that can be carried
    over into K-3 education. Children who miss school for health-related
    reasons or cannot attend to what is being taught cannot be successful
    in school. In addition, HHS has been very successful in promoting
    family involvement and support as two essential elements of high-
    quality early education for at-risk families. Parents whose children
    attend the Head Start program, for example, not only receive services
    and parenting support as part of their child's participation in the
    program, but also are active partners in the child's education,
    weighing in on the curriculum selection and staffing decisions. The
    support that families receive, and the sense of empowerment they feel,
    play a role in positively affecting children's school readiness
    outcomes.
        Question. How many States have applied for State Advisory Council
    funding to date and how do you plan to encourage States to implement
    that requirement of the Head Start Act?
        Answer. We have received six applications for State Advisory
    Council funding. One of these six States has received its funding and a
    second State is about to receive its funding.
        We have been in communication with all 50 States, the 5
    territories, and the District of Columbia and all but a few have
    indicated that they are actively working on completing their
    application. Several intend to submit their applications in May, but
    the majority of States have indicated target submission dates in June
    and July--knowing they have until August 1, 2010 to submit.
        We are mailing a communication to the Governors during the week of
    May 3 asking them to indicate their intent to apply and the target date
    for submittal of their application. We hope to get all responses by the
    end of May and have asked Governor's to fax back their responses by May
    25 allowing us sufficient time to request States to submit an addendum
    to their initial application if they are interested in an additional
    supplemental award subject to the availability of funds.
        Question. I understand that HHS is in the process of writing
    regulations to implement the 2007 amendments to the Head Start Act.
    Where is HHS in this process? When do you expect the new performance
    standards to be released for comment?
        Answer. HHS is in the process of revising the performance standards
    to ensure that they reflect the most recent evidence on the components
    of a high-quality early childhood program. During the revision process,
    the Office of Head Start conducted listening sessions with each of the
    12 regions, including American Indian/Alaska Native and Migrant and
    Seasonal Head Start, as well as a parent focus group and a national
    stakeholder group in order to incorporate input from grantees. HHS
    expects to publish a Notice of Proposed Rulemaking (NPRM) for public
    comment before the end of the year.
        HHS also is drafting a regulation that establishes a designation
    renewal system to determine if a Head Start agency is delivering a
    high-quality and comprehensive Head Start program. HHS expects to
    publish an NPRM by this fall.

                            BREAST CANCER SCREENING

        Question. Secretary Sebelius, the President's budget would cut $4
    million from the National Breast and Cervical Cancer Early Detection
    Program (NBCCEDP). If I'm doing the figures correctly, that funding
    level would result in 7,000 fewer cancer screenings next year. Is that
    true? How do you expect to transition this program as new legislation
    is enacted to extend insurance and preventive screenings in particular?
        Answer. The fiscal year 2011 President's budget requests $211
    million for the NBCCEDP, which is $4 million below fiscal year 2010.
    This reduction is part of a CDC-wide effort to achieve efficiencies in
    travel and contracting and to maintain the program's impact with the
    goal of funding the same the number of cancer screenings. Thus, the
    proposed travel and contract reductions will not have any programmatic
    impact on the NBCCEDP activities. Regarding the provisions in the
    Affordable Care Act that extends coverage for recommended cancer
    screening services, CDC is actively exploring innovative ways to
    increase and improve cancer screenings. These approaches include using
    policy and systems change strategies; improving case management and
    care coordination, tailoring outreach to underserved communities;
    improving quality assurance of screening services; enhancing
    surveillance to monitor screening use and quality; and increasing
    education and awareness for the public and providers. CDC is also
    working to identify what the remaining uninsured population may be
    beyond 2014 and looking to define potential roles that State and local
    health departments could play in quality assurance and delivery of
    preventive services.

                                BLOOD DISORDERS

        Question. The President's budget proposes consolidating a number of
    programs in the CDC. In particular, I'm concerned about the plan for
    funding around blood disorders? Can you give me some details on CDC's
    plans for the blood disorders programs in fiscal year 2011? What
    activities will be supported and at what funding level?
        Answer. The fiscal year 2011 President's budget requests $20
    million for a program that realigns CDC's Blood Disorders Program to
    address the public health challenges associated with blood disorders
    and related secondary conditions. Rather than fund a disease-specific
    program for specific categories of blood disorders, the new program
    uses a comprehensive and coordinated agenda to prioritize population-
    based programs targeting the most prevalent blood disorders. This
    public health approach will impact as many as 4 million people
    suffering with a blood disorder in the United States versus
    approximately 20,000 under the current programmatic model. This
    approach builds upon the successful collaboration CDC has with the
    national network of hemophilia treatment centers as well as the
    thrombosis and thalassemia centers. In fiscal year 2011, CDC plans to
    focus on the following three areas of greatest burden and unmet need:
    deep vein thrombosis and pulmonary embolism, hemoglobinopathies (such
    as sickle cell disease and thalassemia), and bleeding disorders. By
    using this broader approach, CDC anticipates increased program
    efficiencies by merging and re-designing data collection systems from
    those that focus on single disorders to a single system that collects
    data needed for monitoring health outcomes for multiple disease and
    disorders.

                                  TOBACCO LAB

        Question. Madam Secretary, as you know, last year the Family
    Smoking Prevention and Tobacco Control Act became law. That bill gave
    authority to the HHS to regulate tobacco for the first time, however,
    that bill would not have been possible without the detailed information
    gathered by the smoking lab at the CDC. I understand the FDA is working
    on developing their own laboratory to test tobacco products. What
    functions do you foresee FDA taking over and what functions will CDC
    retain? How are the CDC and the FDA coordinating the transition?
        Answer. FDA is responsible for the regulation of tobacco products
    and the administration of the Family Smoking Prevention and Tobacco
    Control Act, among other statutes. FDA executes its regulatory and
    public health responsibilities in four areas: protecting the public
    health, scientific standard-setting and product review, compliance and
    regulation, and public education and outreach. Comparatively, CDC
    performs research and surveillance to further the scientific
    understanding of how chemical composition and product design influence
    the health consequences of tobacco products, to provide a scientific
    basis for evaluating risk, and to aid public health officials in
    evaluating the effectiveness of tobacco control measures. As we move
    forward, CDC will continue to perform these functions. As FDA
    implements this historic piece of legislation, CDC and FDA are
    coordinating efforts, which include developing new methods for
    evaluating the constituents and ingredients in tobacco products;
    evaluating the impact of regulatory actions; and testing tobacco
    products and constituents.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye

                         COMMUNITY HEALTH CENTERS (CHC)

        Question. Senator Burdick and I were instrumental in the
    establishment of the National Institute for Nursing Research (NINR) and
    for 25 years the Institute has been dedicated to improving the health
    and healthcare of Americans through the funding of nursing research and
    research training. Since it was established, the Institute has focused
    on promoting and improving the health of individuals, families,
    communities, and populations. How does the (National Institutes of
    Health) NIH plan to further expand this critical arm of research?
        Answer. The fiscal year 2011 budget request includes $150.2
    million, and increase of $4.6 million above the fiscal year 2010
    appropriation, for the National Institute of Nursing Research (NINR).
    NINR continues to support and advance innovative research studies in
    self-management, symptom management, caregiving; health promotion and
    disease prevention; research capacity development; technology
    integration; and end-of-life research. NINR has begun to develop their
    next strategic plan which is scheduled for release early in fiscal year
    2012. Stakeholder input, a priority setting process, and public health
    concerns will shape the direction of NINR.
        Question. At my request, the University of Hawaii at Hilo
    established the College of Pharmacy. The College of Pharmacy's
    inaugural class of 90 students began in August 2007, will graduate in
    2011, and will hopefully stay in Hawaii to meet the growing demand for
    pharmacists. Historically, Hawaii's youth interested in becoming
    pharmacists would travel to the mainland for school, and not return. It
    is my vision that the people of Hawaii will have educational
    opportunities in the health professions that will in turn increase
    access to care to residents in rural and underserved communities. Has
    there been any discussion on establishing schools of allied health in
    remote communities to meet the growing needs for healthcare and improve
    access to care in rural America?
        Answer. HRSA programs work to increase access to healthcare in
    rural America through the training of allied health professionals. For
    example, the Area Health Education Centers (AHEC) Program encourages
    the establishment and maintenance of community-based training programs
    in off-campus rural and underserved areas in an overall effort to
    attract students into health careers with an emphasis on careers in the
    delivery of primary care to underserved populations. The program works
    to train culturally competent health professionals who will return to
    their home communities and provide healthcare to the underserved. In
    fiscal year 2008, the AHEC Program provided education and training to
    approximately 4,000 allied health students in community-based rural
    training sites.
        Question. America faces a shortage of nurse faculty, further
    complicating the problems of the nursing shortage. According to a study
    conducted by the American Association of Colleges of Nursing in 2008,
    schools of nursing turned away 49,948 qualified applicants to
    baccalaureate and graduate nursing programs. The top reason cited for
    not accepting these potential students was a lack of qualified nurse
    faculty. This element of the shortage has created a negative chain
    reaction--without more nurse faculty, additional nurses cannot be
    educated; and without more nurses, the shortage will continue. What
    efforts has the Department of Health and Human Services (HHS) made to
    address the shortage of qualified nurse faculty?
        Answer. HRSA's principal tools for addressing the nurse faculty
    shortage are the Nurse Faculty Loan Program (NFLP) and the Advanced
    Education Nursing (AEN) Program. The NFLP makes grants to schools that
    provide low-interest loans to nurse faculty students and then cancel a
    portion of the loans when the individual completes a service
    commitment. The AEN program provides grants to nursing schools to
    develop and operate advanced practice nursing training programs, as
    well as to provide traineeship support to students. During the latest
    reporting period covering academic year 2008-2009, fiscal year 2008,
    133 schools participated in the NFLP facilitating the graduation of 223
    students qualified to fill nurse faculty positions. During the same
    period, 194 NFLP graduates reported employment as nurse faculty. In
    fiscal year 2009, 149 schools participated with an estimated 1,100
    students receiving loans to support their education to become faculty.
    Grantees report that the NFLP has facilitated the graduation of 764
    students qualified to fill nurse faculty positions.
        The NFLP also received funding under the American Recovery and
    Reinvestment Act (ARRA). In fiscal year 2009, these funds were used to
    provide additional support to 65 (included in the 149) schools of
    nursing to support an estimated 500 additional students for a total of
    1,600 students receiving funding from regular appropriations and ARRA.
    In fiscal year 2010, the remaining ARRA funds will be used to make an
    estimated 700 additional loans.
        In fiscal year 2009, 160 AEN Program grants were awarded to schools
    of nursing. Twenty-one of the projects focused specifically on
    innovative teaching and learning content to prepare nurse educators. We
    estimate that 160 grants will be awarded in fiscal year 2010.
        Question. Using Hawaii as an example, what happens when a State is
    unable to pay health plans contracted to provide access to care for
    Medicaid beneficiaries? In this particular case, the Governor has
    apparently refused to release funds necessary to draw down Federal
    matching funds designated for the State's Medicaid Program. Does the
    department have any remedies in place to mandate that the States make
    funds available to ensure access to care for Medicaid beneficiaries?
        Answer. Our goal is to address payment issues before they impact
    Medicaid beneficiaries' access to care. In any case where Centers for
    Medicare & Medicaid Services (CMS) hears a State is contemplating a
    payment delay, our regional office staff work with the States to
    understand the impact of any delays on plans and beneficiaries and,
    where appropriate, to identify alternative approaches. We are aware
    that Hawaii is planning to delay its contractual payments to Medicaid
    managed care organizations (MCOs) in order to postpone payments to the
    next State fiscal year. The CMS is working aggressively with the State
    to share our concerns and ensure that the delayed payments to the MCOs
    do not result in the MCOs' inability to pay their network providers or
    otherwise impact beneficiary access.
        Question. With your increased focus on prevention, it seems as
    though a natural partnership would be with the community health centers
    whose focus is on public health and prevention. Has the department
    explored any collaborative partnership ideas with the Centers for
    Disease Control and Prevention (CDC) and the CHCs?
        Answer. HRSA convened a 3-day meeting with CDC in November of 2009
    to explore opportunities for continued collaboration. HRSA has been
    working closely with CDC on the HHS Healthy Weight Initiative as well
    as the Tobacco Prevention and Control Initiative. Additionally, HRSA is
    partnering with CDC on improving HIV screening and testing within
    health centers.
        Question. In regards to partnerships, rural areas in States like
    Hawaii and Alaska may have community health centers and/or an Indian
    Health Service (in Alaska) or Tribal Health facility. What, if any,
    type of collaboration has taken place in ensuring rural residents
    receive healthcare closest to home?
        Answer. HHS works with each health center organization to identify
    the need for primary care services for the underserved and vulnerable
    populations in their respective service areas. HHS encourages health
    centers to identify additional existing primary care providers in the
    area, and to collaborate with them so that the target populations
    receive appropriate levels of care for their needs. Nationally, there
    are 7 jointly funded CHC and Urban Indian Health Clinics. In addition,
    19 tribal entities currently receive section 330 health center funding
    to provide care within their communities.
        Question. On November 21, 1989, section 218 of Public Law 101-166
    stated that the NIH building No. 36 is hereby named the Lowell P.
    Weicker Building and on May 30, 1991, the NIH dedicated building 36 to
    Governor Weicker. During NIH campus renovations, the Weicker building
    was destroyed to make room for a Neuroscience Research Center. Has the
    NIH given any consideration to preserving the honorable recognition of
    Governor Lowell P. Weicker?
        Answer. NIH is currently reviewing the status of existing
    facilities on our campus, including the naming of buildings. However,
    naming another building for Senator Weicker, or any individual,
    requires congressional action.
                                     ______

                  Questions Submitted by Senator Patty Murray

                    WORKFORCE/SUSTAINABLE GROWTH RATE (SGR)

        Question. I was glad to hear you talk about the need to support and
    strengthen our healthcare workforce. I know how important it is to
    ensure that our workforce needs are met. As we work to ensure quality,
    affordable healthcare coverage for all Americans, we must make sure
    there are enough qualified professionals to provide that care. This is
    why I led the charge to write a strong workforce title in the HELP
    healthcare reform bill. I was also glad to hear in your testimony
    particular focus on ensuring that America's senior population gets the
    care and treatment it needs. And one of the greatest barriers to that
    is the unfair and inequitable way that Medicare reimburses doctors and
    providers using the deeply flawed SGR formula. I have heard from so
    many doctors across my home State of Washington who have had to re-
    evaluate their ability to treat Medicare patients. Some have decided to
    turn away new Medicare patients, while others have been forced to drop
    them all together. We need to do something about this. The President's
    budget includes $371 billion over 10 years to address physician
    payments. The budget seems to assume that Congress will pass a serious
    of short-term patches rather than a single permanent fix, and it
    reflects zero growth in the fee schedule. But short-term solutions
    aren't enough. Without a more equitable and accurate system of
    reimbursement, doctors will continue to worry about being paid for
    doing their job, and seniors will find it harder and harder to access
    the care they need. This is especially true in areas like my home State
    of Washington where doctors and hospitals are penalized for treating
    patients efficiently and well. So my questions are: What is the
    administration's policy on a long-term fix to the SGR?
        Answer. The administration supports comprehensive, but fiscally
    responsible reforms to the physician payment formula. We also believe
    that Medicare and the country need to move toward a system in which
    doctors face incentives for providing high-quality care rather than
    simply ``more'' care--a principle reflected in the Affordable Care
    Act's (ACA) payment and delivery reforms.
        I look forward to working with you and your colleagues in Congress
    to reform Medicare's payment methodology for physicians' services to
    address these concerns in a sustainable and responsible manner.
        Question. Why was a long-term solution for this problem not
    addressed in the President's fiscal year 2011 budget?
        Answer. The President's fiscal year 2011 budget request reflected
    the likely cost of providing zero percent annual payment updates for
    physicians--an honest budgeting approach to reflect the expected cost
    of truly addressing this policy. To that end, the fiscal year 2011
    budget includes an adjustment totaling $371 billion over 10 years
    (fiscal year 2011-fiscal year 2020) to reflect the administration's
    best estimate of future congressional action, based on Congress'
    repeated interventions on scheduled physician payment reductions in
    recent years. However, this adjustment does not signal a specific
    administration policy. Rather, the administration intends to continue
    to work with Congress to jointly develop a long-term solution to the
    physician reimbursement formula.

                                    TITLE X

        Question. I was pleased to hear you mention in your testimony the
    investment the President's budget makes in science-based teen-pregnancy
    prevention initiatives. Another proven program that helps prevent
    unintended pregnancies is the title X program, which is the only
    Federal program exclusively dedicated to family planning and
    reproductive-health services. Publicly funded family-planning services
    have helped reduce the rates of unintended pregnancy and abortion in
    the United States, and in fact, the Centers for Disease Control and
    Prevention (CDC) has included family planning on its list of the top 10
    most valuable public-health achievements of the 20th century. I was
    pleased to see that the President's budget again calls for an increase
    in title X funding. Do you agree that, in order to reduce the need for
    abortion, we must invest in valuable family planning services?
        Answer. Yes, publicly funded family planning services provided
    under the title X program play an important role in preventing teen and
    unintended pregnancy. During 2008, family planning services were
    provided through title X-funded clinics to more than 5 million
    individuals, 24 percent of whom were under the age of 20. It is
    estimated that the contraceptive services provided through the title X
    family planning program helped to prevent almost 1 million unintended
    pregnancies during 2008.

                     TEEN-PREGNANCY PREVENTION INITIATIVES

        Question. Last year's fiscal year 2010 omnibus eliminated funding
    for rigid abstinence-only-until-marriage programs, which by law were
    required to have nonmarital abstinence promotion as their ``exclusive
    purpose'' and were prohibited from discussing the benefits of
    contraception. In sharp contrast, the new approach--championed by this
    subcommittee--will focus on programs that have demonstrated their
    effectiveness, and all funded programs will be required to be age
    appropriate and medically accurate. The next step is for administration
    officials to draft the more detailed rules and regulations to determine
    which specific programs get funded. When is the Office of Adolescent
    Health (OAH) expected to release its request for proposals and how will
    it determine which programs are eligible for funding under this new
    initiative? How do you anticipate distributing the funds?
        Answer. OAH has released three Funding Opportunity Announcements
    (FOA). The ``Tier 1'' FOA for replicating programs that have proven
    effective through rigorous evaluation was released on April 2, 2010.
    Applicants may apply in 1 of 4 funding ranges:
      --Range A.--$400,000 to $600,000 per year
      --Range B.--$600,000 to $1,000,000 per year
      --Range C.--$1,000,000 to $1,500,000 per year
      --Range D.--$1,500,000 to $4,000,000 per year
        The ``Tier 2'' FOA for innovative approaches to teen pregnancy
    prevention was released on April 9, 2010, in conjunction with the
    Administration for Children and Families (ACF) Personal Responsibility
    Education Program funds reserved for innovative youth pregnancy
    prevention strategies. Applicants may apply in 1 of 2 funding ranges:
      --Range A.--$400,000 to $600,000 per year
      --Range B.--$600,000 to $1,000,000 per year
        A third FOA, which will also use Tier 2 funds in collaboration with
    CDC, provides funds for demonstrating the effectiveness of multi-
    component, community-wide approaches to teenage pregnancy prevention;
    was released on May 4, 2010. Applicants may apply in 1 of 2 funding
    ranges:
      --Range A.--$750,000 to $1,500,000 per year
      --Range B.--$300,000 to $700,000 per year
        All three FOA's will be subject to a competitive peer-review
    process.
        Under a contract with the Department of Health and Human Services
    (HHS), Mathematical Policy Research (MPR) conducted an independent,
    systematic review of the evidence base. This review defined the
    criteria for the quality of an evaluation study and the strength of
    evidence for a particular intervention. Based on these criteria, HHS
    has defined a set of rigorous standards an evaluation must meet for a
    program to be considered effective and therefore eligible for funding
    under this announcement.
        Applicants were requested to review the list of evidence-based
    curriculum and youth development programs which HHS identified as
    having met these standards. A summary listing of these interventions
    was published in appendix A of the FOA. Program models listed in
    appendix A are eligible for replication under this funding
    announcement. Applicants that wish to replicate a program that is not
    on the list in Appendix A, may apply to do so, but a set of stringent
    criteria, described below, must be met.
        More detailed information about the review process and the programs
    eligible for replication is available at: http://www.hhs.gov/ophs/oah.
        If an applicant wants to apply to replicate a program model that is
    not on the list in appendix A, all of the following criteria must be
    met to qualify for funding under this FOA:
      --The research or evaluation of the program model that the applicant
            seeks to replicate was not previously reviewed.
      --There is research on or evaluations of the program model that meet
            the screening and evidence criteria used for the review of the
            other program models.
      --The application must include all relevant research and evaluation
            information.
      --The application must be submitted by May 17, 2010 to provide for
            the time that will be needed to review the evidence submitted.
        Tier 1 final award decisions will be made by the Director of the
    OAH. Tier 2 final award decisions will be made collaboratively by the
    Director of OAH and the Commissioner of ACYF. In making decisions, the
    Director and the Commissioner will take into account the score and rank
    order given by the Objective Review Committee, and other considerations
    as follows:
        The availability of funds.
      --Representation of evidence-based teenage pregnancy prevention
            programs across communities, including varied types of
            interventions and evidence-based strategies.
      --Geographic distribution nationwide.
      --Inclusion of communities of varying sizes, including rural,
            suburban, and urban communities.
      --Feasibility of evaluation plan (for applications in Tier 1 Ranges C
            and D and Tier 2).
      --Inclusion of a range of populations disproportionately affected by
            teenage pregnancy.
        Question. In determining which programs or group of programs are
    (or are not) effective, both the quality of a study and the magnitude
    of a program's impact are crucial. A large body of evidence shows that
    more comprehensive approaches--those that encourage abstinence, but
    also contraceptive use for young people who are having sex--can be
    effective. But rigid, moralistic, abstinence-only-until-marriage
    programs of the type promoted under previous Federal policy have been
    found in study after study not to be effective. How will the
    administration define a program as effective or promising?
        Answer. Under a contract with HHS, MPR conducted an independent
    systematic review of the evidence base for programs to prevent teen
    pregnancy. This review defined the criteria for the quality of an
    evaluation study and the strength of evidence for a particular
    intervention. Based on these criteria, HHS has defined a set of
    rigorous standards an evaluation must meet in order for a program to be
    considered effective and therefore eligible for funding as an evidence-
    based program under Tier 1 of the new teenage pregnancy prevention
    program. The MPR review had four steps:
      --Find Potentially Relevant Studies.--Studies were identified by a
            review of reference lists from earlier research syntheses, a
            public call for studies to solicit new and unpublished
            research, a search of relevant research and policy
            organizations' Web sites, and keyword searches of electronic
            databases. Nearly 1,000 potentially relevant studies were
            identified.
      --Screen Studies To Review.--To be eligible for review, a study had
            to examine the effects of an intervention using quantitative
            data and statistical analysis. It had to estimate program
            impacts on a relevant outcome-sexual activity (for example,
            delayed sexual initiation), contraceptive use, sexually
            transmitted infections (STIs), pregnancy, or births. The study
            had to focus on United States youth ages 19 or younger and have
            been conducted or published since 1989. A total of 199 studies
            met these screening criteria.
      --Assess Quality of Studies.--Impact studies that met the screening
            criteria were reviewed by trained MPR staff and assigned a
            rating of high, moderate, or low based on the rigorous and
            thorough execution of their research designs. The high rating
            was reserved for random assignment studies with low attrition
            of sample members and no sample reassignment. The moderate
            rating was given to quasi-experimental designs with well-
            matched comparison groups at baseline, and to certain random
            assignment studies that did not meet all the criteria for the
            high rating.
      --Assess Evidence of Effectiveness.--A framework was developed for
            grouping programs into different evidence categories, based on
            the impact findings of studies meeting the criteria for a high
            or moderate rating. HHS then defined which of these categories
            would be eligible for funding. To qualify for funding, a
            program had to be supported by at least one high- or moderate-
            rated impact study showing a positive, statistically
            significant impact on at least one priority outcome (sexual
            activity, contraceptive use, STIs, pregnancy, or births), for
            either the full study sample or key subgroup (defined by gender
            or baseline sexual experience).
        In total, 28 programs met the funding criteria, reflecting a range
    of program models and target populations. Of those programs, 20 had
    evidence of impacts on sexual activity (for example, sexual initiation,
    number of partners, or frequency of sexual activity), 9 on
    contraceptive use, 4 on STIs, and 5 on pregnancy or births.
        Question. As the President's principal advisor on health-related
    matters, how do you plan to work with the President to promote
    responsible sex education for young people?
        Answer. I have made reducing teen and unintended pregnancies one of
    my areas for key interagency collaborations at HHS. I have identified
    the several strategies to reduce teen and unintended pregnancy that are
    comprehensive in nature, cross organizational boundaries, and focus on
    the evidence of what works both in the public health and social
    services arenas.
        In addressing these strategies, HHS will draw upon the expertise of
    the public health and human services parts of HHS, including the ACF,
    the Office of the Assistant Secretary for Planning and Evaluation
    (ASPE), the CDC, the Health Resources and Services Administration
    (HRSA), the National Institutes of Health (NIH), the newly created OAH
    and the Office of Population Affairs (OPA) within the Office of Public
    Health and Science. Key among the strategies are:
      --Invest in Evidence-based Teen Pregnancy Reduction Strategies and
            Continue To Develop the Evidence-based Practice.--HHS will
            employ a comprehensive, evidence-based approach to reducing
            teen pregnancy. Under the newly funded Teen Pregnancy
            Prevention Program, HHS will fund the replication of models
            that have been rigorously evaluated and shown to be effective
            at reducing teen pregnancy or other behavioral risk factors as
            well as research and demonstration projects designed to test
            innovative strategies to prevent teen pregnancy. By conducting
            high-quality evaluations of both types of approaches--those
            replicating evidence-based models and innovative strategies--
            this initiative will expand the evidence base and uncover new
            ways to address this issue. Additional funding made available
            under the ACA will provide formula grants to States to fund
            evidence based models and test new strategies as well. ACF,
            ASPE, CDC, OAH, and OPA will each play a critical role in these
            efforts.
      --Target Populations at Highest Risk for Teen Pregnancy.--HHS efforts
            will focus on demographic groups that have the highest teen
            pregnancy rates, including Hispanic, African-American, and
            American Indian youth, and target services to high-risk,
            vulnerable and culturally under-represented youth populations,
            including youth in foster care, runaway and homeless youth,
            youth with HIV/AIDS, youth living in areas with high teen birth
            rates, delinquent youth, and youth who are disconnected from
            usual service delivery systems.
            sexually transmitted diseases (stds) prevention in teens
        Question. Unintended teen pregnancy is not the only negative sexual
    health outcome facing America's young people. One young person every
    hour is infected with HIV and young people ages 15-25 contract about
    one-half of the 19 million STDs annually, even though they make up only
    one-quarter of the sexually active population. By focusing the funding
    only on teen pregnancy prevention, and not including the equally
    important health issues of STDs and HIV, it seems that an opportunity
    has been missed to provide true, comprehensive sex education that
    promotes healthy behaviors and relationships for all young people,
    including lesbian, gay, bisexual, and transgender youth. So many
    negative health outcomes are inter-related and educators on the ground
    know that they best serve young people when they address the inter-
    related health needs of young people. What is the administration's
    position on making this a comprehensive prevention initiative that
    addresses the inter-related health needs of adolescents, including
    unintended pregnancy, STD, and HIV prevention?
        Answer. As the review of the evidence revealed, 28 programs met the
    funding criteria, reflecting a range of program models and target
    populations. And these results also support the inter-relatedness of
    health needs of adolescents. Of those 28 programs, 20 had evidence of
    impacts on sexual activity (for example, sexual initiation, number of
    partners, or frequency of sexual activity), 9 on contraceptive use, 4
    on STIs, and 5 on pregnancy or births.
        Addressing the health needs of adolescents is very important to me.
    Specifically, I have made reducing teen and unintended pregnancy and
    supporting the National HIV/AIDS strategy two of my key areas for
    interagency collaborations at HHS. (As well as a strategic initiative
    to prevent and reduce tobacco use that includes national campaigns to
    prevent and reduce youth tobacco use.) I have identified the following
    set of strategies to reduce teen and unintended pregnancy.
        In addressing these strategies, HHS will draw upon the expertise of
    the public health and human services parts of the Department, including
    the ACF, ASPE, CDC, HRSA, NIH, the newly created OAH, and OPA within
    the Office of Public Health and Science.
      --Invest in Evidence-based Teen Pregnancy Reduction Strategies and
            Continue To Develop the Evidence-based Practice.--HHS will
            employ a comprehensive, evidence-based approach to reducing
            teen pregnancy. Under the newly funded Teen Pregnancy
            Prevention Program, HHS will fund the replication of models
            that have been rigorously evaluated and shown to be effective
            at reducing teen pregnancy or other behavioral risk factors as
            well as research and demonstration projects designed to test
            innovative strategies to prevent teen pregnancy. By conducting
            high-quality evaluations of both types of approaches--those
            replicating evidence-based models and innovative strategies--
            this initiative will expand the evidence base and uncover new
            ways to address this issue. Additional funding made available
            under the ACA will provide formula grants to States to fund
            evidence based models and test new strategies as well. ACF,
            ASPE, CDC, OAH, and OPA will each play a critical role in these
            efforts.
      --Target Populations at Highest Risk for Teen Pregnancy.--HHS efforts
            will focus on demographic groups that have the highest teen
            pregnancy rates, including Hispanic, African-American, and
            American Indian youth, and target services to high-risk,
            vulnerable, and culturally under-represented youth populations,
            including youth in foster care, runaway and homeless youth,
            youth with HIV/AIDS, youth living in areas with high teen birth
            rates, delinquent youth, and youth who are disconnected from
            usual service delivery systems.
      --Increase Access to Clinical Services--HHS will ensure access to a
            broad range of family planning and related preventive health
            services, including patient education and counseling; STI and
            HIV prevention education, testing, and referral. Services can
            be provided through community health centers, title X family
            planning clinics, and public programs. HHS-funded health
            services under the title X family planning program will
            encourage family participation in the decision of minors to
            seek family planning services and provide counseling to minors
            on ways to resist attempts to coerce them into engaging in
            sexual activity.

                            ANTIMICROBIAL RESISTANCE

        Question. The World Health Organization (WHO) has identified
    antimicrobial resistance as one of the three greatest threats to human
    health. Two recent reports demonstrate that there are few candidate
    drugs in the pipeline to treat infections due to highly drug-resistant
    bacteria. One of these reports, for example, found only 15
    antibacterial drugs in the development pipeline, with only 5 having
    progressed to clinical trials to confirm clinical efficacy (phase III
    or later). Are there any plans to create a seamless approach to the
    research and development of new antibacterial drugs, particularly those
    designed to combat gram-negative infections, to ease the transition
    across the spectrum of enterprise from basic research to product
    development and procurement? What other actions can NIH/National
    Institute of Allergy and Infectious Diseases (NIAID) take to ensure
    that these needed new antibacterial drugs become available as soon as
    possible?
        Answer. The NIAID conducts and supports basic research to identify
    new antimicrobial targets and translational research to apply this
    information to the development of therapeutics; to advance the
    development of new and improved diagnostic tools for infections; and to
    create safe and effective vaccines to control infectious diseases and
    thereby limit the need for antimicrobial drugs.
        NIAID provides a broad array of pre-clinical and clinical research
    resources and services to researchers in academia and industry designed
    to facilitate the movement of a product from bench to bedside. By
    providing these critical services to the research community, NIAID can
    help to bridge gaps in the product development pipeline and lower the
    financial risks incurred by industry to develop novel antimicrobials.
    NIAID is attuned to the need for antimicrobials for Gram-negative
    bacteria and is working with several biotechnology companies and
    pharmaceutical companies to develop novel agents. NIAID also is
    conducting studies to inform the rational use of existing antimicrobial
    drugs or alternative therapies to help limit the development of
    antimicrobial resistance.
        In addition, development of broad spectrum antibiotics is a key
    program in the portfolio of medical countermeasures that HHS'
    Biomedical Advanced Development Authority (BARDA) uses to address the
    medical consequences of biothreats like anthrax, plague, tularemia, or
    enhanced bacterial threats that are antibiotic resistance. BARDA's
    efforts focus on development of these products toward licensure and
    stockpiling after NIAID and industry have shown proof of principle for
    the antibiotic candidates. BARDA supports industry in the advanced
    development of new antibiotics through cost-reimbursement contracts.
    BARDA continues to look for new and improved ways to support
    development of new antibiotics to treat newly emerging bacterial
    pathogens with antibiotic resistance.

                           VACCINE-PREVENTABLE DEATHS

        Question. We have been extremely successful in reducing the number
    of vaccine-preventable deaths in children. Unfortunately, we still have
    around 45,000 such deaths each year in adults. Millions of American
    adults go without routine and recommended vaccinations because our
    medical system is not set up to ensure adults receive regular
    preventive healthcare, which costs us about $10 billion annually in
    direct healthcare costs. What plans does CDC have for programs to
    increase the numbers of adults who receive vaccinations each year?
        Answer. One area of focus of CDC's adult immunization efforts is to
    increase influenza vaccination rates among healthcare workers. CDC is
    collaborating with the Centers for Medicare and Medicaid Services to
    explore public reporting of influenza vaccination rates among this high
    risk population as a quality performance measure for healthcare
    institutions. CDC is also working with State immunization programs to
    maintain the number of providers and partnerships that were developed
    out of the H1N1 response, including obstetricians and gynecologists,
    internists, pharmacists, and school-located vaccination clinics.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu

         FOSTERING CONNECTIONS TO SUCCESS AND INCREASING ADOPTIONS ACT

        Question. Last year, Congress passed the Fostering Connections to
    Success and Increasing Adoptions Act with the intention of reforming
    the foster care and child welfare system. Many States have reported
    difficulties in implementing the provisions outlined in the bill and
    are looking for additional guidance from the Department of Health and
    Human Services (HHS). What is HHS doing to help States implement these
    reforms? How can we continue to provide reforms to transform the child
    welfare system so that it is efficient and promotes permanent placement
    of children in families rather than long-term foster or institutional
    care?
        Answer. HHS is committed to ensuring the safety, permanency, and
    well-being of children, particularly those who are at risk of entering
    or are already in the child welfare system. To that end, we are working
    hard to implement the many reforms made through the Fostering
    Connections to Success and Increasing Adoptions Act.
        We have issued a number of policy guidance documents and program
    instructions on Fostering Connections and continue to address
    additional questions from States and tribes. For example, we have
    issued detailed guidance on how a State or tribe can take up the option
    of the new Title IV-E Guardianship Assistance Program and submit claims
    for Federal reimbursement.
        HHS is also focused specifically on implementing a number of
    initiatives to achieve permanency in a timely manner for children so
    that they do not end up in long-term foster or institutional care. For
    example, the President's new fiscal year 2010 long-term foster care
    initiative is a $20 million, 5-year demonstration grant program
    engaging States, localities, tribes, and private organizations in
    implementing innovative intervention strategies aimed at reducing the
    number of children who stay in foster care for extended periods of
    time. In addition to funding services, the initiative awards grantees
    bonus funding for demonstrating improvement in the outcomes for
    children who have been in foster care for an extended period of time or
    who are at risk of remaining in foster care for long periods. We will
    conduct a rigorous national cross-site evaluation of the demonstration
    to determine whether this approach is successful and can be replicated.
    HHS also continues to work in collaboration with States to engage in
    program improvement efforts that reduce barriers to permanency as
    identified through the Child and Family Service Reviews. Further, HHS
    is actively engaged in raising the profile of the needs of children in
    need of permanency through our support for the AdoptUsKids initiative.
    This initiative focuses on the adoption of older youth and other
    children who remain in foster care for the longest periods. As of March
    2010, more than 12,000 foster children previously featured on the
    initiative's Web site found permanent, adoptive homes.
        Finally, we are providing assistance to States and tribes on
    Fostering Connections and permanency initiatives through a
    comprehensive network of training and technical assistance partners.
    This network includes National Resource Centers and regional
    Implementation Centers that focus on in-depth and long-term
    consultation and support to States and tribes to execute strategies to
    achieve sustainable, systemic change for greater safety, permanency,
    and well-being for families.
        We look forward to working with the subcommittee on additional
    reforms that may achieve permanency for our Nation's most vulnerable
    children.

                             MENTAL HEALTH SERVICES

        Question. Providing mental health services in the wake of a
    disaster and during the recovery is critical to the community, however,
    the system seems to be fragmented. How can we coordinate the work so
    that children especially can get the support that they need?
        Answer. Emergency Support Function (ESF) #8 of the National
    Response Framework, the Federal Government's guiding principles for a
    unified national response to disasters and emergencies, lays out the
    principles for providing public health and medical services during
    disasters and emergencies. These services explicitly include mental and
    behavioral health. The Office of the Assistant Secretary for
    Preparedness and Response (ASPR) in its coordination role for ESF #8
    actively works with ESF #8 partners to identify and address mental
    health needs, including those of children that are appropriate for
    Federal assistance. During a response, the Emergency Management Group
    (EMG) utilizes behavioral health subject matter experts within the ASPR
    Division of At-risk, Behavioral Health, and Community Resilience to
    provide guidance, assist with triage of State requests for assistance,
    and support coordination efforts as needed between the EMG, HHS
    Operating Divisions like the Substance Abuse and Mental Health Services
    Administration (SAMHSA), ESF #8 partners like the American Red Cross,
    and affected States' Disaster Behavioral Health Coordinators.
        Additionally, in order to provide the needed mental health services
    and supports following a disaster and into the recovery period, the
    Federal Emergency Management Administration (FEMA) and SAMHSA
    coordinate to support State and local mental health networks through
    financial support, training, and technical assistance.
        FEMA funds several grants targeted to areas with Presidentially
    declared disasters for which SAMHSA--through its Emergency Mental
    Health Management and Traumatic Stress Services Branch at the Center
    for Mental Health Services--provides technical assistance, program
    guidance, and oversight. Among these funding opportunities are Crisis
    Counseling Assistance and Training Program (CCP) grants to increase
    local mental health staff and provide outreach and education for States
    which have identified a gap in mental health resources following a
    disaster. CCP Immediate Services Program grants to State mental health
    authorities to provide up to 60 days of funding for services
    immediately following the declaration of a disaster, and CCP Regular
    Services Program grants can provide an additional 9 months of support
    following a disaster. Supplementary funding is also available for
    special circumstances.
        In ongoing efforts, SAMHSA collaborates with FEMA to provide
    training--including annual trainings--to State mental health staff to
    develop crisis counseling training and preparedness plans and to
    encourage State-to-State information exchange. SAMHSA also maintains
    the Disaster Technical Assistance Center and the Disaster Behavioral
    Health Information Series to provide toolkits and a readily available
    source of information--including information specifically focused on
    children and adolescent mental health--to assist States, territories,
    and local entities in delivering effective mental healthcare during
    disasters.
        Additionally, the National Commission on Children and Disasters
    (NCDD) was established to carryout a comprehensive study to examine and
    assess the needs of children as they relate to preparation for,
    response to, and recovery from disasters. Through its interim report
    released last October, NCDD identified gaps and shortcomings in the
    provision of mental health services to children in disasters and made
    recommendations that will be used to inform legislative and executive
    branch policies and programs.
        In order to address the concerns of NCDD, HHS' ASPR has established
    a monthly meeting with the Commissioners to discuss HHS's progress.
    Additionally, this month, the ASPR and the Assistant Secretary for
    Children and Families will begin convening an HHS Working Group on
    Children and Disasters to facilitate communication and collaboration
    across the Department to improve the coordination of services for
    children--including mental and behavior health services--before,
    during, and after disasters and emergencies.

                            COMMUNITY HEALTH CENTERS

        Question. The primary care community health centers created to fill
    the need after Hurricane Katrina have proved to be an extremely
    successful model to keep the uninsured and under-insured out of the
    emergency room. How can we provide ongoing support for successful
    programs like this?
        Answer. The fiscal year 2011 President's budget request includes an
    increase of $290 million for the Health Center program to continue the
    American Recovery and Reinvestment Act investment in 127 Health Center
    New Access Points as well as the services initiated under the Increased
    Demand for Services grants to health centers nationwide. This funding
    level will also support the development of approximately 25 new access
    points, increasing access to comprehensive primary healthcare services
    to an estimated 150,000 additional health center patients.
    Additionally, this level will support an estimated 125 service
    expansion grants to expand the integration of behavioral health into
    existing primary healthcare systems, enhancing the availability and
    quality of addiction care at existing health centers.

                               HEALTHCARE REFORM

        Question. What is your perspective on healthcare reform, its impact
    on State budgets, and the cost of healthcare for those who currently
    have insurance?
        Answer. Health insurance reform ensures a strong Federal-State
    partnership and does not strain State budgets. Specifically, health
    insurance reform: provides new, additional funding to States to support
    coverage expansions; strengthens States' roles in insurance oversight,
    delivery system reform, and prevention; reduces Medicaid and Medicare
    costs; reduces State uncompensated care; ends the ``hidden tax'' to
    finance care for the uninsured; eliminates the need for most State-
    funded coverage programs; creates jobs, spurs the local economy and
    generates tax revenues; and invests in community health centers.
        In terms of healthcare costs for families: In its analysis, the
    nonpartisan Congressional Budget Office confirmed that lower
    administrative costs, increased competition, and better pooling for
    risk will mean lower average premiums for American families:
      --Americans buying comparable health plans to what they have today in
            the individual market would see premiums fall by 14 to 20
            percent.
      --Most Americans buying coverage on their own would qualify for tax
            credits that would reduce their premiums by an average of
            nearly 60 percent--even as they get better coverage than what
            they have today.
      --Those who get coverage through their employer today will likely see
            a decrease in premiums as well.
      --And Americans who currently struggle to find coverage today would
            see lower premiums because more people will be covered.
                                     ______

                Questions Submitted by Senator Richard J. Durbin

                               MEDICAID COVERAGE

        Question. An article in the New York Times on March 15, 2010,
    entitled, ``As Medicaid Payments Shrink, Patients Are Abandoned,''
    highlighted what I have been hearing from Illinois providers for some
    time now. In this difficult economy, States are squeezing payments to
    providers in Medicaid at the same time the economy is fueling
    continuous growth in enrollment. As a result, patients are finding it
    increasingly difficult to locate doctors and dentists who will accept
    their Medicaid coverage. Many of the providers in Illinois tell us they
    cannot afford to take Medicaid patients. As a result, many delay care
    or forego it altogether, or end up going to hospital emergency rooms.
    Can you speak to the importance of provider payments in Medicaid, the
    impact on patient care, and any consideration the Department of Health
    and Human Services (HHS) has given to providing additional incentives
    to States to increase their payment rates?
        Answer. The administration recognizes the importance of adequate
    Medicaid provider payment rates and is pleased that the Health Care and
    Education Reconciliation Act of 2010 increases Medicaid payments to
    primary care physicians for calendars years 2013 and 2014. As a former
    Governor, I understand the tough choices States have to make when
    facing a difficult economy. However, I also recognize that Medicaid
    provider payment rates can affect access to care, and therefore is an
    area ripe for examination. I expect the newly formed Medicaid and CHIP
    Payment Advisory Commission will provide helpful guidance to enable us
    to undertake more robust consideration of Medicaid rates so that we can
    ensure all Medicaid beneficiaries have access to the healthcare
    providers they need.

                        CRITICAL ACCESS HOSPITALS (CAH)

        Question. CAHs are, by definition, critically important to rural
    communities throughout Illinois. Within CAHs, there is a heavy reliance
    on anesthesia services provided by certified registered nurse
    anesthetists (CRNA). CRNAs are the sole anesthesia providers in the
    vast majority of rural hospitals. Without CRNA services, many U.S.
    rural and CAHs would not be able to offer care. Recent rulings by the
    Centers for Medicare and Medicaid Services (CMS) have denied rural
    hospitals' claims for tens of thousands of dollars each in annual
    Medicare funding that they had come to rely upon to serve their
    communities. In addition, due to recent reclassifications of certain
    CAHs from rural to urban and as being located in a ``Lugar'' county,
    CMS has denied ``pass-through'' payment to these facilities for CRNA
    services. Can you advise the subcommittee on the potential for
    revisiting the CMS policy of denying reimbursement for on-call costs of
    CRNA services in the Rural Pass-through Program and the policy of
    denying payments to CAHs that have recently been reclassified as urban
    and in Lugar counties?
        Answer. With respect to on-call costs of CRNA services in CAHs,
    section 1834(g)(5) of the Social Security Act (SSA) states that in
    determining the reasonable costs of outpatient CAH services, the
    Secretary recognizes as allowable costs amounts for ``physicians,
    physician assistants, nurse practitioners, and clinical nurse
    specialists who are on-call (as defined by the Secretary) to provide
    emergency services but who are not present on the premises of the
    critical access hospital involved.'' The statute is explicit in
    allowing Medicare payment for on-call costs only of these designated
    practitioners and only for emergency services in CAHs. Accordingly, CMS
    does not have the authority to pay for on-call costs of CRNA services.
        With respect to pass-through payments for CRNAs, in the fiscal year
    2011 hospital inpatient prospective payment system (IPPS) proposed rule
    published on May 4, we are proposing to permit urban hospitals that
    have been classified as rural under section 1886(d)(8)(E) of the SSA to
    be paid on the basis of reasonable costs for anesthesia services and
    related care furnished by a qualified nonphysician anesthetist. We are
    not proposing to change our policy that would permit Lugar hospitals to
    be paid reasonable costs for such services. As stated in the proposed
    rule, Lugar facilities are considered urban under section 1886(d) of
    the SSA, and therefore, we do not believe it would be consistent with
    the statute to permit these facilities, which are not considered rural,
    to be paid on the basis of reasonable costs for CRNA services.

                          HEALTH PROFESSIONS PROGRAMS

        Question. The University of Illinois at Chicago (UIC) is the
    largest medical school in the United States, and it houses the largest
    component of minority students in the country, including the largest
    single training center for Latino medical students and third largest
    for African-American students. In fact, 70 percent of the minority
    physicians in Chicago and 60 percent of those in the State were trained
    at UIC. I commend the administration's investment in the Minority
    Centers of Excellence program and the Health Career Opportunity
    Program, increasing funding for these two programs for the first time
    in years. What other plans does HHS have to ensure a diverse healthcare
    workforce and for a robust health professions pipeline programs at
    Health Resources and Services Administration (HRSA) in fiscal year
    2011?
        Answer. The administration prioritizes increasing the diversity of
    the health professions workforce and views it as a key strategy for
    increasing access to healthcare and reducing health disparities. In
    fact, HHS invested $50 million of the $200 million in American Recovery
    and Reinvestment Act (ARRA) funds designated for workforce programs in
    programs that specifically focus on increasing the diversity of the
    workforce. More than 50 percent of students in HRSA's Bureau of Health
    Professions-funded training programs are from minority and/or
    disadvantaged backgrounds. This year HRSA engaged its stakeholders to
    discuss strategies for increasing the diversity of the health
    professions workforce and for measuring the effectiveness of these
    strategies. In fiscal year 2011, HRSA will continue to implement
    program improvements that can result in a more diverse workforce.
        Question. I have noted that health professionals graduating from
    the minority health professions schools have a propensity to practice
    in medically underserved areas, many times community health centers.
    However, the existing Graduate Medical Education Program does little,
    if anything, to promote the practice of residents in underserved areas
    or in settings outside of the traditional hospital. What can we do to
    highlight this relationship and strengthen the pipeline from the
    minority health institutions to the community health centers with
    financial resources already allocated?
        Answer. With a looming shortage of primary care professionals and
    increased attention on preventive medicine, we acknowledge the value of
    training more residents in nonhospital sites and it is our intent to
    make sure Medicare medical education rules encourage and facilitate
    this kind of activity.
        Medicare permits hospitals to receive indirect medical education
    and other medical education payments for those residents training in
    nonhospital sites if the hospital incurs ``all or substantially all the
    costs'' of the training at those sites. The Affordable Care Act (ACA)
    clarifies this standard by requiring hospitals to pay stipends and
    benefits for trainees in nontraditional settings. The ACA also provides
    other avenues to encourage training in nonhospital settings, including
    financial support for teaching health centers, increased funding for
    primary care, and a 5-year, $230 million program to support the
    expansion of primary care residency programs in community-based
    teaching health centers.
        Question. The workforce shortages in State and local health
    departments have been well-documented. The President's budget for
    fiscal year 2011 includes a new proposal for a Health Prevention Corps
    (HPC). Can you elaborate about how this proposal will help address
    workforce shortages in State and local health departments, and how the
    Centers for Disease Control and Prevention (CDC) plans to recruit a
    diverse work force into this field?
        Answer. The fiscal year 2011 President's budget requests $10
    million for the HPC, which will recruit, train, and place participants
    in State and local health departments to fill positions in disciplines
    with documented workforce shortages. While HPC participants are
    learning on the job, they will also provide direct service to their
    health department and the State or local jurisdiction, such as by
    participating in public health surveillance activities, supporting
    outbreak investigations or environmental health assessments, or
    identifying important biologic specimens. CDC plans to ensure diversity
    among the HPC participants by recruiting strategically through social
    networking, student associations (including minority student
    associations), college career counselors, student and school listservs,
    alumni associations, and university/college organizations.

                          CHILDHOOD OBESITY PREVENTION

        Question. I'm very pleased to see that childhood obesity prevention
    has been an important priority for this administration and particularly
    the First Lady. CDC has invested in research and strategic partnerships
    to develop best practices in nutrition and physical activity. How has
    the CDC partnered with school systems to put this information into
    practice, and what additional steps could be taken in the future to
    ensure that this information is disseminated effectively?
        Answer. CDC supports a variety of programs and activities that
    address childhood overweightness and obesity in school and community
    settings. For instance, CDC's Division of Adolescent and School Health
    provides funding and technical support to 22 State departments of
    education and one tribe to address critical health issues, including
    obesity. CDC also supports school-based activities that contribute to
    obesity prevention and control efforts, such as promoting a systematic,
    data-driven approach to implementing evidence-based school health
    policies and programs, and developing and disseminating tools to help
    schools implement these practices.
        In addition, communities funded through the Healthy Communities
    Program and the Recovery Act Communities Putting Prevention to Work
    Program are partnering with school district leaders and staff to
    address childhood obesity through nutrition and physical activity
    strategies. These programs aim to promote wellness and to provide
    positive, sustainable health change by advancing policy, systems, and
    environmental change approaches, with a strategic focus on obesity
    prevention.

                            COMMUNITY HEALTH CENTERS

        Question. As you know, through the ARRA, we made a historic
    investment in our Nation's community health centers. While this
    investment is reaping benefits in communities across the Nation--
    including more than 35 health centers in Illinois, we know that there
    is still tremendous unmet need in health centers across the country.
    One demonstration of this need was in the competition for Facility
    Investment Program (FIP) funding available to health centers for large-
    scale construction projects through ARRA. Although more than 600
    applications were submitted, only 85 could be approved. Those
    applications are still valid, and I am interested in the potential for
    funding these high-scoring, but unfunded applications. In addition, can
    you project how many jobs could be created if Congress were to provide
    additional funds for health center FIP funding in the range of $2
    billion.
        Answer. As you note, significant interest has been expressed in the
    Health Center Facility Investment Program that was funded through the
    ARRA. The ACA includes an additional $1.5 billion (for fiscal year 2011
    through fiscal year 2015) for investments in health center facilities.
    We envision health centers that applied for ARRA funding being eligible
    for receipt of this funding. At this point, it is difficult to project
    how many jobs will be created through the expenditure of this funding.

                         MEDICARE SECONDARY PAYER (MSP)

        Question. Recently, I have heard concerns regarding the MSP system
    and a beneficiary's privacy. It seems that the current system is making
    it very difficult for many beneficiaries to settle cases and receive
    their settlement funds in the same timeframe as non-Medicare
    beneficiaries. The MSP reporting requirements in section 111 of the
    Medicare and Medicaid Extension Act of 2007 gave the Secretary
    discretion to establish the rules governing this new reporting process.
    I understand that those rules require beneficiaries to provide their
    social security number (SSN) or Medicare health information claim
    numbers (HICN) number to third parties as part of this reporting
    process. In light of our concerns of identity theft and the fact that
    HHS advises beneficiaries to keep these numbers private, what can be
    done so that beneficiaries do not have to disclose this information?
        Answer. HHS and CMS are committed to protecting the identity of
    Medicare beneficiaries and ensuring that they are able to access their
    healthcare benefits in a secure way. The HICN, also known as the
    Medicare number, serves as a beneficiary's identification number for
    Medicare entitlement. An individual may become entitled to Medicare
    through Social Security based on his or her own earnings or that of a
    spouse, parent, or child. HICNs reflect the social security number
    (SSN) of the individual who is entitled to Medicare, preceded or
    followed by a suffix that pertains to the specific beneficiary.
    Therefore, while in many cases a beneficiary's HICN includes their
    personal SSN, it is not always the case.
        Since the MSP process requires CMS to re-examine all billing and
    payments made by Medicare on behalf of a beneficiary, it would be
    impossible to perform this search without using a beneficiary's
    Medicare number, or the HICN. However, I want to assure you that we
    have strong guidelines and procedures in place to ensure that
    beneficiaries are protected from unauthorized disclosure of their
    personal information.
                                     ______

                    Questions Submitted by Senator Jack Reed

                  LOW INCOME HOME ASSISTANCE PROGRAM (LIHEAP)

        Question. I am deeply concerned about the proposed $2 billion cut
    in the LIHEAP block grant, which represents a $13.6 million reduction
    in funding for the State of Rhode Island. While the budget proposal
    calls for the creation of a so-called mandatory ``trigger'' fund to
    make up the difference, there is no certainty that the gap in the block
    grant will be filled for each State. Is it a certainty that the
    mandatory fund will be triggered in fiscal year 2011?
        Answer. Under current economic estimates, substantial mandatory
    funding will be triggered in fiscal year 2011 under the
    administration's legislative proposal. We estimate that $2 billion will
    be released, bringing total LIHEAP funding to $5.3 billion, an increase
    of $200 million above fiscal year 2010.
        Question. If the mandatory fund is triggered, how can States be
    assured that they will not see a cut from the level of funding they
    received in fiscal year 2010 in the absence of any kind of funding
    formula?
        Answer. Under our legislative proposal, the administration would
    determine a State allocation of triggered mandatory funds. A funding
    formula was not proposed because we believe having discretion over
    State allocations provides flexibility necessary to respond to the
    unique aspects of each heating or cooling season. Since we expect
    substantial funds to be triggered by an overall increase in the
    percentage of households receiving Supplemental Nutrition Assistance
    (SNAP) we would expect that States where SNAP usage has increased the
    most would see increased funding compared to fiscal year 2010. The
    discretion provided by the proposal would allow us to address unique
    circumstances. For example, if two States had the same increase in SNAP
    usage, the one experiencing severe weather could receive additional
    funds.
        Question. How are States supposed to plan their programs without a
    clear sense of how much funding they will receive? Why is it not
    simpler and more predictable to fully fund the block grant?
        Answer. Since LIHEAP funding is currently subject to an annual
    appropriation, States must currently plan their programs without
    knowing how much discretionary funding they will receive. LIHEAP
    appropriations are frequently not enacted until mid-winter, several
    months after States begin their heating programs. Under our legislative
    proposal, however, most mandatory funding would be allocated to the
    States at the beginning of the Federal fiscal year, as they start their
    heating programs.
        Question. In the out-years, the budget shows a significant decline
    in funding that will be released under the trigger. Given the
    administration's commitment to capping nonsecurity discretionary
    spending and the reduced baseline established for the block grant in
    this budget (again, $2 billion less than fiscal year 2009 and 2010), it
    will be difficult to make up for the shortfall that will occur on the
    mandatory side. Indeed, it appears that this proposal would lock-in a
    cut to overall LIHEAP funding in future years. How does the
    administration plan to ensure that the program does not experience such
    a cut? Will you propose increased funding for the block grant in future
    years?
        Answer. The administration believes that the $5.3 billion requested
    for LIHEAP is appropriate given the circumstances predicted for fiscal
    year 2011. These circumstances include a significant increase in energy
    prices and a 48 percent increase in the proportion of U.S. households
    receiving SNAP. After fiscal year 2011, current predictions show more
    stable energy prices and significant decreases in the proportion of
    households receiving SNAP. Based on these predictions, the amount of
    mandatory funding that we would project to be released by the trigger
    proposal also declines significantly. Should energy prices increase
    rapidly, and/or SNAP participation remain high, the trigger would
    automatically provide a higher level of mandatory funds. While current
    economic estimates show declining mandatory funding after fiscal year
    2011, the trigger proposal ensures that the amount of mandatory LIHEAP
    funding will be higher automatically if there is an increase in need

                 VACCINATIONS--SECTION 317 IMMUNIZATION PROGRAM

        Question. In 2009, the Centers for Disease Control and Prevention
    (CDC) submitted a report to Congress which illustrated that the section
    317 immunization program requires additional funding to carry out its
    essential public health mission of protecting Americans from
    preventable diseases. I am pleased that the American recovery and
    Reinvestment Act (ARRA) began to address this funding need. For the
    first time, entire families in some States received the Tetanus-
    Diphtheria-Pertussis vaccine. In other States, children were able to
    receive their annual influenza vaccine in their school, which helped
    keep children in the classroom, not sick at home. With the success that
    we have seen over the past year, how did you reach the decision to not
    maintain this enhanced funding level in the proposed fiscal year 2011
    budget?
        Answer. The support that the ARRA provided to CDC's section 317
    Immunization Program was one-time funding. The fiscal year 2011
    President's budget requests $579 million, which is +$17 million above
    fiscal year 2010. CDC will continue support for the purchase of vaccine
    and for State immunization infrastructure and operations so that public
    health departments can provide vaccine underinsured and uninsured
    children and adults. With these efforts, CDC plans to keep childhood
    immunization rates at record high levels in the United States.

                         HEALTHCARE WORKER VACCINATION

        Question. Healthcare workers are in direct contact with individuals
    who are often highly susceptible to contracting other diseases and
    conditions. As such, ensuring that health workers, not just patients,
    receive vaccinations are not just a matter of wellness, but also
    patient safety. Unfortunately, we know from a recent reports that only
    40 percent of health workers nationwide, for example, receive annual
    flu vaccinations. Recognizing that this was a problem, hospitals in my
    State of Rhode Island are required to report flu vaccination rates of
    health workers to the Department of Health. Individual health workers
    actually accept or decline (for a specified reason) their vaccine at
    their place of employment, which has increased the rate of vaccination
    in just the past few years. What could be done at the national level to
    increase vaccination rates among healthcare workers?
        Answer. Mandatory healthcare personnel influenza vaccination
    requirements and public reporting of healthcare personnel influenza
    vaccination status has been used to increase coverage rates at the
    healthcare institution and State-levels. CDC is currently working with
    Centers for Medicare and Medicaid Services (CMS) to assess the
    effectiveness and feasibility of establishing a mechanism for public
    reporting of influenza vaccination coverage among healthcare personnel
    by making this a national quality performance measure for healthcare
    institutions.

                      TITLE VII HEALTH PROFESSIONS FUNDING

        Question. We know that a strong healthcare workforce will help to
    meet the healthcare needs of patients around the country. And, as we
    work to pass health reform legislation, we know that the number of new
    individuals who will, for the first time, have access to primary care
    doctors will create even greater strain on the system. For this reason,
    I was pleased that the ARRA provided an additional $200 million to
    train a new generation of healthcare workers. This investment will also
    make a significant economic impact. In 2008, medical schools and
    teaching hospitals had a combined $512 billion impact on the national
    economy. And each trained and practicing primary care doctor, for
    example, has a $1.5 million impact on the economy. How will you work to
    prioritize funding increases that directly impact job creation and
    economic recovery?
        Answer. Health Resources and Services Administration (HRSA) is
    coordinating with the Department of Labor (DOL) to ensure investments
    in health workforce are complimentary, reduce shortages in health
    professions, and provide economic opportunities. HRSA and DOL will soon
    submit to the Congress a joint strategic plan for how they will invest
    their resources in fiscal year 2010 and beyond. One key area of
    emphasis is building career ladders in the healthcare sector. Career
    ladder programs allow individuals to expand their skills and increase
    their income. In fiscal year 2010, Congress appropriated funds for HRSA
    to implement an initiative to improve training for nursing aides and
    home health aides. This initiative will generate more economic
    opportunities for individuals who pursue these careers. According to
    Bureau of Labor statistics, these two occupations are among the fastest
    growing.

                          THE HEMOPHILIA PROGRAM (CDC)

        Question. The President's budget for fiscal year 2011 proposes to
    eliminate CDC's Blood Disorders Division and establishes a new program
    described as ``a public health approach to blood disorders.'' The
    explanation provides few details on what existing activities will be
    maintained or changed and what new activities will be initiated. Can
    you provide a detailed explanation of CDC's new approach, with a
    particular emphasis on how it will impact the cost-effective research,
    treatment, and surveillance conducted under the Hemophilia Program, as
    well as a description of how the $20.4 million will be spent?
        Answer. The fiscal year 2011 President's budget requests $20
    million for a program that realigns CDC's Blood Disorders Division to
    address the public health challenges associated with blood disorders
    and related secondary conditions. Rather than fund a disease-specific
    program for specific categories of blood disorders, the new program
    uses a comprehensive and coordinated agenda to prioritize population-
    based programs targeting the most prevalent blood disorders. This
    public health approach will impact as many as 4 million people
    suffering with a blood disorder in the United States versus
    approximately 20,000 under the current programmatic model. In fiscal
    year 2011, CDC plans to focus on the following three areas of greatest
    burden and unmet need: deep vein thrombosis and pulmonary embolism,
    hemoglobinopathies (such as sickle cell disease and thalassemia), and
    bleeding disorders. CDC has a long and robust history of partnership
    with a national network of 135 hemophilia treatment centers that has a
    documented history of improved health outcomes for hemophilia patients.
    CDC plans to continue this national network for the hemophilia
    population as well as those suffering from the most prevalent blood
    disorders.

                 OCEAN STATE CROHN'S AND COLITIS AREA REGISTRY

        Question. The President's budget eliminates a very successful
    program at the CDC focused on Crohn's disease and ulcerative colitis--
    painful and debilitating diseases. The CDC program supports much-needed
    epidemiology research on these disorders which has been conducted
    exclusively in Rhode Island through the Crohn's and Colitis Foundation
    of America (CCFA). A substantial Federal investment has already been
    made in connecting more than 22 physicians groups and hospitals in
    Rhode Island that are engaged in the research. And CDC Director and
    Administrator Dr. Frieden wrote in a recent letter that, ``[w]e have
    been pleased with the success of our collaboration with CCFA'' and
    ``the registry is meeting its aim to gain insight into the etiology of
    IBD, to learn why the course of illness varies among individuals, and
    determine what factors may improve outcomes.'' If these statements are
    accurate, what is the rationale for eliminating this successful program
    and how can we work together to ensure that existing efforts are
    maintained with adequate Federal funding?
        Answer. For fiscal year 2011, the President's budget does not
    continue the specific $686,000 provided in fiscal year 2010 for
    Inflammatory Bowel Disease (IBD) as the request seeks to eliminate
    duplicative programs that take narrow, disease-specific approaches
    rather than a broader public health approach. CDC will continue to
    provide technical assistance to partners who are researching the
    natural history of IBD and factors that predict the course of the
    disease. This research includes studies examining provider variation in
    the treatment of Crohn's disease, disparities in mortality for IBD
    patients, disparities in surveillance for colorectal cancer associated
    with this disease, and variation in outcomes in relation to race.
                                     ______

                    Question Submitted by Senator Mark Pryor

                                   ABSTINENCE

        Question. The Consolidated Appropriations Act, 2010, established a
    funding stream for a new Teen Pregnancy Prevention Program. The
    Conference Report included language providing $110,000,000 for a new
    teenage pregnancy prevention initiative. The Conference Report
    underscored the value of abstinence: ``The conferees intend that
    programs funded under this initiative will stress the value of
    abstinence and provide age-appropriate information to youth that is
    scientifically and medically accurate.'' It is my understanding that
    Arkansas and other States' programs dedicated to abstinence education
    would likely be able to apply for funds from a $25 million pool of
    research and development grant program funding, but no guarantee exists
    that these programs would receive continued funding and they could be
    eliminated.
        Answer. Twenty-eight different programs met the funding criteria,
    reflecting a range of program models and target populations, some
    included abstinence components. States such as Arkansas may select one
    of these models and apply under tier 1 or may apply under the tier 2
    innovative approaches pool from either the Teen Pregnancy Prevention
    funds in OS or the Personal Responsibility Education Program (PREP)
    innovative strategies funds in ACF. Additionally, the department of
    Health and Human Services is still determining the funding process for
    the PREP evidence-based replication programs which totals approximately
    $55 million and is designed to educate adolescents on a number of
    personal responsibility areas including abstinence. In addition, the
    Patient Protection and Affordable Care Act includes $50 million in
    annual mandatory funding for States to provide abstinence education,
    which may be a source of support for these programs.
                                     ______

                  Questions Submitted by Senator Arlen Specter

                 AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA)

        Question. Madam Secretary, the Department Health and Human Services
    (HHS) fiscal year 2011 budget presented provides an increase of $1
    billion. While this would appear to be a satisfactory amount, when
    taking into account the stimulus funding provided for the National
    Institutes of Health (NIH) which will be coming to an end this year,
    the reduction is catastrophic. The stimulus funds have brought a
    resurgence of scientists to labs to find cures to the greatest maladies
    of our times. Given the need to continue this funding please explain
    HHS's thinking behind this $1 billion increase.
        Answer. The fiscal year 2011 budget request does not fully continue
    the one-time ARRA funding expected to be obligated in fiscal year 2010.
    NIH planned for most of the research supported by the ARRA to be
    completed in 1 or 2 years, or to supplement and accelerate ongoing
    research. However, NIH does plan to use part of its $1 billion budgeted
    increase in fiscal year 2011 to continue specific initiatives begun or
    expanded with ARRA funds. Examples of such projects being continued
    with fiscal year 2011 funds include using The Cancer Genome Atlas to
    catalog all of the reasons why normal cells become malignant;
    shortening the time it takes to develop and test new cancer treatments
    through the Accelerating Clinical Trials of Novel Oncologic Pathways
    Program; sequencing candidate genes to identify genetic contributors to
    autism spectrum disorder; and strengthening the NIH Basic Behavioral
    and Social Sciences Opportunity Network initiative.
        Question. Last year, President Obama signed an executive order to
    expand the number of embryonic stem cell lines that are eligible for
    Federal funding. Last year $143 million (including ARRA funds) was
    spent on human embryonic research by the NIH. Do you believe that
    funding level was sufficient and what we can expect for fiscal year
    2011?
        Answer. Funding levels have not been the limiting factor in the
    support of human embryonic research. The major limitations have been
    the restrictions on the number of stem cell lines available for
    research and the quantity of applications submitted. President Obama's
    Executive Order 13505 of March 9, 2009, removing previous Federal
    restrictions, and NIH's new stem cell research guidelines of July 7,
    2009, implementing the Executive Order has gone a long way in
    addressing these past limitations. Currently, NIH has formally approved
    64 human embryonic stem cell lines to be eligible for Federal research
    support. NIH estimates it will spend at least $126 million in fiscal
    year 2011 on human embryonic stem cell research, an increase of $38
    million, or 43 percent, more than fiscal year 2008 levels.
        I would also mention that on February 26, 2010, NIH announced a new
    initiative to use its Common Fund resources beginning in fiscal year
    2010 to establish an intramural Induced Pluripotent Stem Cell Center to
    drive the translation of scientific knowledge about stem cell biology
    into new cell-based treatments. The capability of transforming human
    skin fibroblasts and other cells into induced pluripotent stem cells
    could lead to major advances in therapeutic replacement of damaged or
    abnormal tissue without risk of transplant rejection.
        With this opening up of Federal support for human embryonic stem
    cells, and with the development of induced pluripotent stem cells,
    researchers will have an unprecedented opportunity in fiscal years 2010
    and 2011 to understand the earliest stages of human development, and to
    explore powerful new therapeutic approaches to Parkinson's disease,
    type 1 diabetes, spinal cord injury, and a long list of rare genetic
    diseases.

                                MEDICARE PART D

        Question. Prior to Medicare Part D, when Medicaid was the primary
    payer of medications in long-term care, pharmacies were required to
    provide a credit for unused medication in most States. As a result,
    pharmacies looked for ways to reduce or reuse the medications, which
    helped curb the amount of waste. However, since the inception of
    Medicare Part D, which has no mechanism to provide a credit for unused
    medication, waste has grown significantly, costing taxpayers billions
    and contaminating our water supplies. Because of the current
    reimbursement system in Part D, long-term care pharmacies have no
    incentive to reduce medication waste. Is medication waste in long-term
    care something the agency is paying attention to and what steps can the
    agency take to eliminate this waste? Are you considering any
    incentives, such as higher dispensing fees for long-term care
    pharmacies and/or technology and research grants?
        Answer. Thank you for the question Senator Specter. Centers for
    Medicare and Medicaid Services (CMS) shares your concern regarding the
    wasteful dispensing of prescription drugs in long-term care settings.
    We have been addressing medication waste concerns as we work toward
    implementing the provision in the Affordable Care Act (ACA) which we
    worked on with Congress to ensure that prescription drugs are dispensed
    with a higher degree of efficiency. The ACA requires part D plans to
    implement waste reduction techniques beginning with the 2012 plan year.
    We are in the process of consulting with key stakeholders such as
    pharmacists, nursing homes, and plans as we develop utilization
    management techniques that will reduce the waste associated with the
    dispensing of 30-day refills in long-term care settings.

                             BIOPRODUCTION FACILITY

        Question. On May 20, 2009, we met to discuss the establishment of a
    facility to develop and manufacture biologics. Since that time we have
    seen the production of H1N1 vaccine fall woefully short, missing the
    delivery date for vaccines by months. A public/private manufacturing
    and development facility would help ensure access to vaccines and other
    medical countermeasures for Americans. I have worked with Biomedical
    Advanced Research and Development Authority (BARDA) to move this
    project forward and they have indicated their support. Could you
    explain why funding for this important project was not included in your
    budget?
        Answer. HHS is currently conducting a review of medical
    countermeasure (MCM) development, which will examine domestic
    manufacturing capacity for pandemic influenza vaccines and other MCMs.
    HHS is also working with the Department of Defense in order to
    coordinate countermeasure facility needs.
        The fiscal year 2010 budget for BARDA includes $5 million to
    support the initial planning phase of core services (formerly called
    bioproduction facilities). HHS plans to solicit proposals and award
    contracts to support architectural and mechanical engineering concept
    design for potential facilities. The goal will be to evaluate the
    potential of strategic partnerships between the Federal Government,
    major biopharmaceutical companies, and smaller biotech companies to
    create domestic-based, flexible, multi-product manufacturing facilities
    focused on providing countermeasure services. Priority services would
    include the advanced development and manufacturing of biological
    medical countermeasures with limited or no commercial markets.

                                ANTHRAX VACCINE

        Question. It is my understanding that the Department has a
    requirement and need to contract for additional doses of the Food and
    Drug Administration (FDA) licensed anthrax vaccine because the number
    of the doses in the Strategic National Stockpile currently are well
    below the total needed to meet HHS's 75 million anthrax vaccine dose
    requirement and the shelf-life dates for using the earlier stockpiled
    anthrax vaccine doses have expired and others will continue to expire.
    It is also my understanding that with the termination of an earlier
    contract and delays in the development of new experimental anthrax
    vaccines, HHS now estimates that it will take at least 8 years before
    potential development and FDA licensure of new anthrax vaccines. Given
    that many Government and other experts are saying that the number one
    WMD threat is anthrax and there is a continuing need for protecting
    first responders and citizens from another potential anthrax attack
    with both vaccines and drugs, what are your plans and timing for
    contracting for additional doses of the current FDA licensed vaccine to
    replenish the stockpile and move toward meeting the 75 million dose
    stockpile requirement?
        Answer. The medical countermeasure review will propose enhancements
    to the countermeasure production process, addressing promising
    discoveries, advanced development, robust manufacturing, including for
    MCMs for anthrax threats.
        The Centers for Disease Control and Prevention (CDC) currently has
    a contract in place with Emergent for procurement of additional 14.5
    million doses of FDA-licensed anthrax vaccine in order to move toward
    meeting the 75 million dose stockpile requirement, and is receiving the
    full production capacity of this vaccine.
        BARDA terminated on December 7, 2009 a solicitation under Project
    BioShield RFP for rPA anthrax vaccine after multiple technical
    evaluation panels determined that none of the proposal from Offerors
    were able to meet the maximum statutory requirement of reaching FDA
    licensure within 8 years. On the same day, BARDA issued special
    instructions under their broad agency announcement to support advanced
    development of next generation anthrax vaccines including rPA vaccine
    candidates. Proposals were received, reviewed, and are currently under
    contract negotiations with an expectation to issue contract awards in
    fiscal year 2010.
        Question. Given the delays and uncertainties with the development,
    procurement, manufacture, and availability associated with vaccines in
    general and most recently for the pandemic vaccine, would it not be
    prudent now for HHS to enter into negotiations as early as possible for
    procurement of a multi-year supply of the anthrax vaccine for the
    stockpile to assure that we are better prepared to respond to an
    anthrax attack or multiple attacks?
        Answer. CDC currently has a contract, with a multi-year contracting
    mechanism to ensure preparedness, in place with Emergent for
    procurement of additional 14.5 million doses of FDA-licensed anthrax
    vaccine in order to move toward meeting the 75 million dose stockpile
    requirement, and is receiving the full production capacity of this
    vaccine.

                              SUBCOMMITTEE RECESS

        Senator Harkin. Same here. The subcommittee will stand
    recessed. Thank you, Madam.
        [Whereupon, at 3:58 p.m., Wednesday, March 10, 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 2011

                                  ----------

                            TUESDAY, MARCH 23, 2010

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

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. HILDA L. SOLIS, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Subcommittee on Labor, Health, Human
    Services, Education, and Related Agencies will come to order.
        Welcome back to the subcommittee, Madam Secretary. I thank
    you for adjusting your time to come a little early.
        We are boarding the bus at 10:15 a.m. to go to the White
    House, and I don't want to miss this historic occasion, to be
    there for signing of the healthcare reform bill. I might point
    out I have my Franklin Roosevelt tie on today, as a reminder of
    what we are about to witness, and the momentous occasion that's
    going to take place this morning with President Obama signing
    the healthcare bill into law. So, thank you for coming up
    early.
        Well, Madam Secretary, just a few comments, here. First of
    all, thanks to President Obama and to the team he has around
    him, including you, and thanks to actions taken by Congress in
    the recovery bill, it seems that the economy is stabilizing.
    But, still far too many people do not have a job. The national
    unemployment rate officially stands at 9.7 percent; that's
    about 14.9 million Americans out of work. But we know there's
    another 8 to 9 million people out there that want to work full
    time, can work full time, but the jobs just aren't available.
        Now, we know the situation could have been worse. The
    Congressional Budget Office recently estimated that roughly 2
    million workers had jobs last quarter because of the Recovery
    Act. Two million. Today, more than 200 construction workers are
    helping build a new Job Corps Center at the Ottumwa Campus of
    the Indian Hills Community College in my State of Iowa. Madam
    Secretary, you were there for me last year when we broke ground
    for this center. These construction jobs were made possible by
    $23 million in Recovery Act funds.
        And I just noticed that Dr. Lindenmayer, who is the
    president of Indian Hills Community College, is here today with
    some students from the Denison Job Corps Center. And I want to
    welcome them here today. Again, this is why we're doing this,
    to focus on the job force, our Nation's workforce of the
    future.

                            FISCAL YEAR 2011 BUDGET

        Madam Secretary, your fiscal year 2011 budget builds on the
    foundations set by the Recovery Act and the 2010 appropriations
    bill. You have proposed key investments in workforce
    innovation, green job training, and I compliment you for that.
    Your budget would also continue the Disability Employment
    Initiative that we started last year in the 2010 appropriations
    bill. Again, more than 20 million disabled Americans are not
    participating in our workforce. That's a missed opportunity. We
    must do better. And I thank you for continuing this program in
    your budget.
        The downturn in the economy also means that workers' rights
    are more vulnerable to employer abuse or misunderstanding. Your
    budget proposes important investments that will help address
    worker misclassification, workplace safety, health activities,
    and, of course, international labor rights. I'm particularly
    pleased to see a proposed increase for Bureau of International
    Labor Affairs (ILAB), which leads our fight against the worst
    forms of child labor around the world. Thank you for that.
        Lastly, this budget does not simply propose to spend more
    money, it proposes to ensure the money is spent wisely. Your
    budget requests $40 million for 5 rigorous evaluations of DOL
    activities. These evaluations will help us learn how to best
    structure our DOL programs so they can operate more efficiently
    and effectively.

                   PROPOSED FREEZE ON DISCRETIONARY SPENDING

        Madam Secretary, as you know the President has proposed a
    freeze on all nondefense discretionary spending for this year,
    so the choices we have as appropriators this year in writing
    our bill will not be easy ones. So, your testimony and your
    continued working with us will help keep us informed us as we
    try to shoehorn in all that we want to do within the
    President's proposal and to not have any increases.
        So, now I turn it over to Secretary Hilda Solis, sworn in
    as the 25th Secretary of Labor on February 24, 2009. I was
    privileged to be there to watch this very historic occasion.
    Prior to her confirmation, she served as a representative of
    the 32nd Congressional District in California. Secretary Solis
    is a noted leader on the issue of clean energy jobs, as well as
    training for veterans, displaced workers, at-risk youth, and
    improving the overall lives of disadvantaged and everyday
    working families. A graduate of California State Polytechnic
    University, got her master of public administration from the
    University of Southern California. As a former Federal
    employee, she worked in the Carter White House Office of
    Hispanic Affairs and as a management analyst with Office of
    Management and Budget in the in the Civil Rights Division.
        So, we were all very delighted when the President asked you
    to be his Secretary of Labor not only because of your knowledge
    of how we work up here, but because of your background as well.
    You brought a wealth of experience to this, and I think the
    last year has shown that. Thank you very much for your great
    leadership, and the floor is yours.

                    SUMMARY STATEMENT OF HON. HILDA L. SOLIS

        Secretary Solis. Thank you very much, Mr. Chairman.
        And, to the Vice Chairman, who isn't with us, and to the
    other subcommittee members, I want to thank you for inviting me
    here today to discuss our fiscal year 2011 budget and our
    request.
        I'd like to review selected highlights of my testimony with
    you.

                             RECOVERY ACT RESOURCES

        First, I want to begin by saying that it's not possible to
    discuss next year's budget without acknowledging the immediate
    need to put people back to work. And you said it very
    pointedly. I'm proud of the work that we have done with the
    Recovery Act resources, including the assistance that was
    provided through the unemployment program, the Unemployment
    Insurance (UI) and COBRA benefits programs; the creation of
    nearly, 318,000 summer jobs for our youth; and the training
    opportunities that we created, particularly in health careers;
    and for jobs in the new green economy.

                               UNEMPLOYMENT RATE

        While these efforts are helping, they are clearly not
    sufficient and not enough. At the 9.7 percent unemployment
    rate, which remains persistently and unacceptably high, I know
    that you have been working hard with your colleagues to reach
    consensus on measures that will allow us to continue to help
    all Americans until the labor market fully recovers.
        There have been, clearly, some setbacks. But, as my
    testimony indicates, I hope that we can commit $1.2 billion to
    ensure a robust summer jobs program this year. And I want to
    thank, in particular, Senator Murray and yourself, Chairman
    Harkin, for your work on this particular issue, and pledge to
    work with you to see that we get this done. I would also like
    to see a jumpstart in our employment through a $500 million
    investment on the job training programs and add funding to
    further support our oversubscribed training programs.

                         WORKFORCE INVESTMENT PROGRAMS

        We then need to sustain these investments through programs
    that give workers the tools they need to succeed in the 21st
    century economy. And I want to highlight some of the measures
    in our budget request that will accomplish this goal.
        For the first time in more than a decade, the budget
    proposes a significant increase in funding for the Workforce
    Investment (WIA), programs. As you know, my team has been
    pleased to work closely with you and your staff on the process
    of WIA reauthorization. Following our approach in that process,
    the additional resources we're requesting for WIA are
    inextricably linked to reform through the establishment of two
    new WIA innovation funds.

                           GREEN JOBS INNOVATION FUND

        The budget also requests an increase of $45 million for
    Green Jobs Innovation Fund. And I can tell you from our
    experience with the Recovery Act, these competitions were very,
    very demanding. We had an enormous number of applicants that
    applied for this funding. So, the need is very great. We know
    that there are some wonderful partnerships that are out there,
    but our resources were limited and we couldn't fund all of
    them. Additional resources would allow us to meet this demand,
    connecting trainees with jobs by requiring that grantees work
    with employers to ensure that participants gain the necessary
    skills and industry-recognized credentials that will help them
    move into better and higher-paying jobs.

                        DISABILITY EMPLOYMENT INITIATIVE

        Mr. Chairman, based on the approach that you championed
    this year, two Department of Labor (DOL) agencies--Employment
    and Training Administration (ETA) and the Office of Disability
    Employment (ODEP)--will continue to receive $12 million each to
    continue their joint disability employment initiative to
    increase the capacity of the one-stop system to provide
    accessible services to individuals with disabilities.

                           WORKER PROTECTION PROGRAMS

        I know you understand it can be too easy to exploit workers
    when jobs are scarce. And we need to remain vigilant in
    protecting the rights and safety of our workers. In fiscal year
    2011, our budget continues that vigilance by hiring additional
    enforcement personnel. We build upon the resources you provided
    us with last year, to return our worker protection programs to
    fiscal year 2001 levels or greater, after years--many years of
    decline. To do so, the request includes $1.7 billion,
    equivalent to 10,957 full-time employees, for worker
    protection. This funding level is $67 million, or 4 percent,
    more than last year's level and the agency-by-agency details
    are in my prepared testimony.
        To reinvigorate our regulatory agenda--the request for
    worker protection includes increases to supplement the
    development of regulations in areas such as pensions, worker
    health, and safety.

                           EMPLOYEE MISCLASSIFICATION

        The budget also contains an important interagency effort to
    address employee misclassification. Workers wrongly classified
    as independent contractors are denied critical benefits and
    protections to which they may be entitled to as employees,
    including overtime, health coverage, workers' compensation,
    family medical leave, and unemployment insurance. In addition,
    misclassification results in billions of dollars of loss to the
    Government through unpaid taxes. Our budget includes $25
    million to hire additional enforcement personnel targeted at
    misclassification and to fund competitive grants to help States
    to address this growing problem.
        Restoring our economy requires ensuring the world economy
    is sound and balanced. I firmly believe that our responsibility
    to promote acceptable conditions of work abroad is very, very
    much linked to our worker protection agenda here at home. It is
    with this goal in mind that we're requesting an additional $22
    million for ILAB to increase the monitoring of labor provisions
    of trade agreements, including provisions related to child
    labor, and to support programs to improve labor rights for
    workers with our trading-partner countries.

                               PREPARED STATEMENT

        Before I conclude, I want to say a few words about our
    commitment to ensuring accountability for the resources that
    you entrust us with. This is why my testimony links investments
    to performance outcomes and why we have a new commitment to
    program evaluation. Members of the subcommittee, we all know
    that too many Americans are ready and willing to work, but
    can't find a job. The budget before you will help spur new and
    better job opportunities while fostering safe workplaces and
    respect and dignity for workers' rights. This is what my goal
    of ``Good Jobs for Everyone'' is. And I look forward to working
    with you, Mr. Chairman, to see that vision is fulfilled.
        I'm happy to respond to any questions that you may have.
        [The statement follows:]

                      Prepared Statement of Hilda L. Solis

        Chairman Harkin, Vice Chairman Cochran, and members of the
    subcommittee, thank you for the invitation to testify today. I
    appreciate the opportunity to discuss the fiscal year 2011 budget
    request for the Department of Labor (DOL).
        The total request for DOL in fiscal year 2011 is $116.5 billion and
    17,800 full-time equivalent employees (FTE), of which $17.1 billion is
    before the subcommittee. Of that amount, $14 billion is requested for
    discretionary budget authority. Our budget request will build on the
    $4.8 billion in discretionary as well as the mandatory resources
    included for the Department in the American Recovery and Reinvestment
    Act (ARRA).

                          PUTTING PEOPLE BACK TO WORK

        Workers and their families are hurting in these tough economic
    times. We know that job opportunities and economic security are of
    utmost importance to Americans. During my travels throughout the
    country, I have met many people who expected to be in their peak
    earning years, and yet were struggling to find employment and maintain
    retirement savings. At DOL, we are putting people back to work and
    assisting unemployed workers who need our help. Through ARRA
    investments funded by the Congress, we have:
      --Funded more than $49 billion in benefits to unemployed workers;
      --Created nearly 318,000 summer youth job opportunities;
      --Invested $500 million in training and research for emerging ``green
            jobs'' and another $220 million to help workers pursue careers
            in health care and other high-growth industry sectors;
      --Created more than 18,000 new community service employment
            opportunities for seniors;
      --Provided job-related services to more than 3.2 million unemployment
            insurance claimants;
      --Provided direct assistance to more than 190,000 unemployed workers
            and their families seeking affordable health coverage and the
            COBRA subsidy.
        While these efforts are helping Americans during these difficult
    times, they are clearly not enough. The unemployment rate remains
    persistently and unacceptably high. This administration wants to ensure
    that investments in job creation will continue until the labor market
    fully recovers from the economic downturn. The president has proposed a
    robust package to spur job creation, including new investments in small
    business, infrastructure, and clean energy. In addressing the need for
    additional jobs legislation, the administration supports additional
    job-creating investments in key DOL initiatives:
        First, last summer the ARRA created more than 300,000 summer jobs
    for at-risk youth in 2009, addressing an alarmingly high youth
    unemployment rate. Based on that experience, we believe that local
    areas can expand the program to create up to 350,000 jobs this summer,
    providing work experience to help young people build their futures and
    income their families can use in a weak economy. We can accomplish this
    with an additional $1.2 billion investment in summer and youth
    employment. In keeping with our approach to WIA reauthorization, this
    amount should include $150 million for competitive grants to support
    innovative programs and build knowledge of what strategies, including
    paid work experience, produce the best educational and employment
    outcomes for disconnected youth.
        Second, training programs that bring workers into contact with
    employers form key partnerships that will result in people getting
    jobs. We support an additional $500 million to expand on-the-job
    training, refresh the skills of the long-term unemployed, and link them
    to real employment opportunities as the economy rebounds.
        Third, through grant programs we will be prioritizing training in
    emerging industries where we know there are jobs, such as clean energy,
    an area where we see a lot of potential for additional training
    efforts. The administration supports an additional $300 million to
    continue two ARRA programs--Pathways Out of Poverty Grants ($225
    million) and Energy Training Partnerships ($75 million). For both of
    these programs, we received many more quality applications than we were
    able to fund. As a result, additional resources would allow us to
    quickly fund these high-quality programs.
        We also applaud the action that has been taken to extend
    unemployment benefits and health insurance. These programs ensure a
    continued safety net for individuals who cannot find jobs, and the
    benefits help stimulate the economy by putting money back in workers'
    pockets who then spend it in their local communities. These programs
    are vital, and we look forward to working with Congress to extend the
    duration of these programs.
        We must work together to respond to the plea from millions of
    Americans for job opportunities and assistance. That means that we need
    to create new and better jobs for the 21st century economy. And because
    it is too easy to exploit workers when jobs are scarce, we need to be
    vigilant in protecting the rights and safety of workers. At DOL, my
    strategic vision is to provide good jobs for everyone. Here are some of
    the ways that we define a good job:
      --A good job can support a family by increasing incomes, narrowing
            the wage gap and allowing workplace flexibility.
      --A good job is safe and secure and gives people a voice in the
            workplace.
      --A good job is sustainable and innovative, for example a green job.
      --A good job will help rebuild a strong middle class.
      --A good job provides access to a secure retirement and to adequate
            and affordable health coverage.
        The resources requested in our fiscal year 2011 budget will help to
    make the vision of good jobs for everyone a reality. They will build on
    and leverage the job creation efforts begun with ARRA and continued
    with the fiscal year 2010 appropriation. I am committed to doing my
    best to see that the new jobs created with the economic recovery are
    good jobs that are open to the diverse group that represents the
    workers of the future.

                        PREPARING FOR JOBS OF THE FUTURE

        DOL is looking to prepare workers with the tools they need to
    succeed in the 21st century economy, and for innovative ways to promote
    economic recovery. The fiscal year 2011 budget request for the
    Department's Employment and Training Administration (ETA) is $10.9
    billion in discretionary funds and 1,080 FTE, not including the 148 FTE
    associated with the proposed legislation for foreign labor
    certification application fees. Through innovative program strategies,
    the budget request for ETA will allow DOL to increase the skills of the
    American workforce, while addressing all segments of the population.
    Innovation Funds
        Reflecting the urgent need to prepare workers for 21st century
    jobs, for the first time in more than a decade, the fiscal year 2011
    budget proposes a significant increase in funding for the Workforce
    Investment Act (WIA) grant programs for adults, dislocated workers, and
    youth. The budget requests $3.4 billion for these programs, an increase
    of $209 million above the fiscal year 2010 level. However, the
    additional resources are inextricably linked to reform.
        In keeping with the administration's WIA reauthorization plan, a
    percentage of the funds appropriated for adults, dislocated workers and
    youth will be reserved for the budget's proposed new Partnership for
    Workforce Innovation, which encompasses $321 million of funding in the
    Departments of Labor and Education. At DOL, two new innovation funds
    would provide competitive grants to State and local entities that can
    demonstrate new and promising ways of preparing individuals for jobs of
    the future. There are funds for adults and youth. For adults, the $108
    million Workforce Innovation Fund would be funded through a 5 percent
    reserve from the WIA Adult and Dislocated Worker Programs. Innovation
    funding will be used, in part, to support and test ``learn and earn''
    strategies like on-the-job training and apprenticeships. For youth, the
    $154 million Youth Innovation Fund will be funded by a 15 percent
    reserve of the funds appropriated for Youth; the funds will support
    summer and year-round employment opportunities and ``work experience
    plus'' programs for out-of-school youth. We are confident that the
    partnership for workforce innovation will create strong incentives for
    change that will improve the effectiveness of the WIA programs, and
    provide incentives for States and localities to break down program
    silos and improve service delivery.
    Green Jobs
        The demand for green job training opportunities is enormous--and
    DOL has been unable to keep pace with the record number of applications
    for grants. We believe that this unprecedented level of interest
    represents the need for resources that focus on green jobs training,
    which complements job creation efforts. We also believe this
    demonstrates the need to assist people who are already working, but who
    may be underemployed, to gain skills--and portable credentials--that
    will help them move into better, higher-paying jobs in emerging
    sectors.
        The budget requests $85 million for the Green Jobs Innovation Fund,
    an increase of $45 million (89 percent) from the fiscal year 2010
    appropriation. The request will provide training opportunities for some
    14,110 workers. These funds will support DOL's efforts to achieve its
    high-priority performance goal in the employment and training arena,
    which is aimed at increasing opportunities for America's workers to
    acquire the skills and knowledge to succeed in a knowledge-based
    economy (and includes training more than 120,000 Americans for green
    jobs by June 2012). The budget will also complement the competitive
    grant awards made through the $500 million appropriation included for
    high-growth and emerging industry sectors under ARRA, and the $40
    million provided in the fiscal year 2010 appropriation.
    YouthBuild
        The fiscal year 2011 budget includes $120 million, an increase of
    $17.5 million (17 percent) for YouthBuild to provide an estimated 230
    competitive grants to local organizations for the education and
    training of approximately 7,450 disadvantaged youth age 16-24. Under
    these grants, youth will participate in classroom training and learn
    construction skills by helping to build affordable housing. In fiscal
    year 2011, DOL will continue the ``green'' transition of YouthBuild by
    encouraging connections with other Federal agencies involved in
    creating green jobs--such as the Departments of Energy and Housing and
    Urban Development--in order to leverage resources and new ``green''
    opportunities for YouthBuild participants.
    Transitional Jobs
        The fiscal year 2011 budget proposes that $40 million for second-
    year funding 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, which is a critical part of our jobs agenda, will
    target noncustodial parents to strengthen their workforce skills and
    experience, and help the children who rely on them for support. DOL is
    carrying out this demonstration collaboratively with other Federal
    agencies, such as the Departments of Health and Human Services and
    Justice. In partnership with these agencies, we are working to develop
    and implement a rigorous evaluation strategy for this demonstration.
    Strengthening Unemployment Insurance Integrity and Promoting Re-
            employment
        The severity of the recession has placed great stress on the
    Unemployment Insurance (UI) system, which has paid out unprecedented
    amounts of unemployment compensation. This administration is committed
    to protecting the financial integrity of the UI system, and helping
    unemployed workers return to work as swiftly as possible. In addition
    to providing the funding that States rely on to administer this
    important safety net program, our approach includes:
      --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 $2.632 billion and employer tax evasion by $282
            million over 10 years (net of the income tax offset).
      --A request of $55 million (an increase of $5 million over the fiscal
            year 2010 level) in discretionary funding to support
            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. In fiscal year
            2011, this investment, combined with the $10 million request
            included in State administration, will help 710,000 UI
            beneficiaries find jobs faster. It is expected to save $2.3
            billion over a 10-year period.
        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 (SCSEP)
        The fiscal year 2011 budget proposes $600.5 million for the SCSEP,
    which will support some 61,900 slots for low-income seniors in part-
    time, minimum wage community service jobs. The request continues
    funding at the base amount of the fiscal year 2010 appropriation. As
    you know, in fiscal year 2010 the Congress provided a special multi-
    year appropriation of $225 million to help low-income seniors facing
    special economic challenges, asking that we allocate those funds within
    45 days of enactment. In January 2010, DOL moved quickly to award these
    funds to offer immediate employment opportunities.
    Job Corps
        The budget includes $1.7 billion to operate a nationwide network of
    124 Job Corps centers in fiscal year 2011. Job Corps provides training
    to address the individual needs of at-risk youth and equip them with
    the skills they need to enter the world of work. The fiscal year 2011
    budget sets forth an ambitious agenda to reform and improve the Job
    Corps program's performance. We have begun this agenda in fiscal year
    2010, which includes:
      --Fully integrating Job Corps with DOL's other employment and
            training programs, with the return of the program to the ETA.
      --A rigorous and comprehensive review of Job Corps center operations
            and management to identify areas most in need of reform.
      --Remediation of program performance shortfalls at the lowest
            performing centers.
      --Analysis of contracting practices and procedures to identify
            potential savings and strategies to improve cost effectiveness.
        We are optimistic that our reform agenda will identify ways to
    produce better outcomes at a lower cost. To the extent that our efforts
    produce long-run cost avoidance, rather than near-term savings, the
    budget includes appropriations language that would allow the transfer
    of up to 15 percent of the $105 million appropriation for construction
    to meet center operational needs. This authority was first provided by
    Congress in ARRA. Job Corps received $250 million from ARRA, which it
    is using to fund shovel-ready construction projects that stimulate job
    growth in center communities. In addition, ARRA 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 (VETS)
        We know returning veterans can contribute greatly to our economy.
    For DOL's VETS, the fiscal year 2011 budget request is $262 million and
    234 FTE. The fiscal year 2011 budget includes $41 million for the
    Homeless Veterans Reintegration Program, an increase of $5 million (14
    percent) more than fiscal year 2010. The request will allow the program
    to provide employment and training assistance to more than 25,000
    homeless veterans, and increase our reach to homeless women veterans.
    In addition, the budget requests $8 million for the Transition
    Assistance Program (TAP) for spouses and family members (including
    those with limited English proficiency), an increase of $1 million (14
    percent) from fiscal year 2010. TAP Workshops will enroll roughly an
    additional 15,000 participants worldwide in fiscal year 2011, and play
    a key role in reducing jobless spells and helping service members
    transition successfully to civilian employment.
    State Paid Leave
        Workforce and workplace changes have made it increasingly difficult
    for working families to meet their work and family responsibilities.
    The vast majority of American workers have family care-giving
    responsibilities outside of work and no full-time caregiver at home.
    Nearly half of private-sector workers do not have paid sick leave to
    care for themselves, and even fewer have leave available to care for
    another family member when they are ill. Millions of workers risk
    losing pay--and even their jobs--when they are sick or their children
    are sick. No worker should be placed in that position. Similarly, most
    workers do not have paid family leave--for example, to care for a
    newborn or newly adopted or fostered child.
        State programs that provide for paid leave offer a solution for
    working families who cannot afford to take unpaid leave but need to
    take time off work to care for a newborn, bond with a new child or care
    for themselves and their families. The fiscal year 2011 budget requests
    $50 million for a State Paid Leave Fund to provide grants to help
    States establish paid leave programs.

                     PROTECTING WORKERS' RIGHTS AND SAFETY

        In the jobs of the future as well as in jobs of the present,
    workers should be safe and their rights should be protected. To achieve
    our goal of rebuilding the middle class, we need to level the playing
    field and restore fair play for all working people. The fiscal year
    2011 budget continues our commitment to protect the rights and safety
    of workers by hiring additional enforcement personnel and strengthening
    our regulatory efforts. The request includes $1.7 billion in
    discretionary funds and 10,957 FTE for our worker protection
    activities. This funding level is $67 million (4 percent) and 177 FTE
    above the fiscal year 2010 appropriation. The budget returns the worker
    protection programs to the fiscal year 2001 staffing levels or greater,
    and builds on the progress begun in fiscal year 2010 to restore
    capacity in our worker protection programs.
    Employee Misclassification Initiative
        Employers who misclassify their employees as independent
    contractors often avoid paying the minimum wage and overtime. They
    evade payroll taxes, and often do not pay for workers' compensation or
    other employment benefits. As a result, employees are denied the
    protections and benefits of this Nation's most important employment
    laws, and their employers gain an unfair advantage in the market place.
    Employees are particularly vulnerable to misclassification in these
    difficult economic times. The fiscal year 2011 budget requests $25
    million for a multi-agency initiative to strengthen and coordinate
    Federal and State efforts to enforce statutory prohibitions, and
    identify and deter employee misclassification as independent
    contractors.
        For the Wage and Hour Division (WHD), the fiscal year 2011 budget
    requests an additional $12 million and 90 new investigators to expand
    its efforts to ensure that workers are employed in compliance with the
    laws we enforce. The funds will support targeted investigations that
    focus on industries where misclassification is most likely to lead to
    violations of the law, and training for investigators in the detection
    of workers who have been misclassified.
        The Misclassification Initiative also will support new, targeted
    ETA efforts to recoup unpaid payroll taxes due to misclassification and
    promote the innovative work of States on this problem. This initiative
    includes State audits of problem industries supported by Federal
    audits, and $10.9 million for a pilot program to reward the States that
    are the most successful (or most improved) at detecting and prosecuting
    employers that fail to pay their fair share of taxes due to
    misclassification and other illegal tax schemes that deny the Federal
    and State UI Trust Funds hundreds of millions of dollars annually.
        In addition, the Misclassification Initiative includes:
      --For the Office of the Solicitor, $1.6 million and 10 FTE to support
            enforcement strategies, with a focus on coordination with the
            States on litigation involving the largest multi-State
            employers that routinely abuse independent contractor status.
      --For the Occupational Safety and Health Administration (OSHA),
            $150,000 to train inspectors on worker misclassification
            issues.
      --Legislative changes that will require employers to properly
            classify their workers, provide penalties when they do not, and
            restore protections for employees who have been classified
            improperly.
        With these efforts, we intend to reduce the prevalence of
    misclassification and secure the protections and benefits of the laws
    we enforce. This effort strikes at the core of DOL's mission--and the
    hard working people of this country deserve no less.
    Wage and Hour Division
        I take the failure to pay workers the wages that they have earned
    very seriously, and I am committed to enforcing all employment laws--
    particularly those related to payment of the minimum wage and overtime.
    Workers deserve this money, and it will bring new resources to low-
    income households where most of it will be spent and help reinvigorate
    local communities. As I noted earlier, we have already increased wage
    hour enforcement staffing. At 1,672 FTE, the staffing level for the WHD
    requested in fiscal year 2011 is 29 percent higher than the fiscal year
    2009 level. As new investigators grow into their jobs, they will be an
    even stronger force for securing compliance with basic labor standards
    protections. The fiscal year 2011 budget request of $244.2 million for
    WHD will support targeted investigations, meaningful compliance
    assistance, and--in support of DOL's high-priority performance goals--
    reduce repeat violations of minimum wage, overtime, and workplace
    safety laws.
    Office of Federal Contract Compliance Programs
        I am also committed to vigorously enforcing the laws that combat
    discrimination, for our goal is to protect workers who--ultimately--are
    America's most important asset. The fiscal year 2011 request for the
    Office of Federal Contract Compliance Programs (OFCCP) is $113.4
    million and 788 FTE, an increase of $8 million from the fiscal year
    2010 level. The 2010 appropriation has allowed OFCCP to return to 2001
    staffing levels, and the 2011 request will make it possible to maintain
    that level.
        The fiscal year 2011 budget will allow OFCCP to broaden its
    enforcement efforts and focus on identifying and resolving both
    individual and systemic discrimination. OFCCP will focus its attention
    on a broad range of issues that arise in individual cases, including
    harassment, retaliation, termination, and failure to promote. Since
    Federal contractors are obligated to self-audit and correct identified
    problems, OFCCP will step up monitoring of this element of contractor
    compliance. As part of OFCCP's enforcement of Executive Order 11246,
    Equal Employment Opportunity, a renewed emphasis on conducting
    construction reviews is planned.
    Office of Workers' Compensation Programs
        The fiscal year 2011 discretionary budget request for
    administration of the Office of Workers' Compensation Programs (OWCP)
    totals $127.3 million and 921 FTE to support the Federal Employees'
    Compensation Act (FECA) ($103.5 million), the longshore and harbor
    workers' compensation program ($17.2 million) and $6.6 million for the
    Division of Information Technology Management and Services (DITMS).
    DITMS provides information technology general services support for the
    programs that were previously within the Employment Standards
    Administration (ESA) and was previously funded in ESA's program
    direction and support activity. DITMS was transferred to OWCP with the
    understanding that it would provide the same level of IT support. The
    request includes an additional $3.2 million and 9 FTE to address the
    burgeoning workload under the Defense Base Act arising from claims
    associated with injuries to war-zone contract workers in Afghanistan
    and Iraq.
        A high-priority performance goal for fiscal year 2011 will be a
    new, jointly sponsored OWCP and OSHA initiative entitled ``Protecting
    Our Workforce and Ensuring Reemployment'' (POWER). The new program is
    designed to bring a greater focus on the Federal Government as a model
    employer of workers injured on the job and returning to the workplace,
    or for employing workers with disabilities.
        The OWCP budget also includes mandatory funding totaling $53.8
    million and 295 FTE to administer part B of the Energy Employees
    Occupational Illness Compensation Program Act (EEOICPA), and $72.8
    million and 265 FTE for Part E of the Act. EEOICPA provides
    compensation and medical benefits to employees or survivors of
    employees of the Department of Energy 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 Department of Energy contractor
    facilities.
        Lastly, OWCP's fiscal year 2011 budget includes $38.3 million in
    mandatory funding and 198 FTE for its administration of parts B and C
    of the Black Lung Benefits Act, and $58.4 million and 127 FTE in FECA
    Fair Share administrative funding.
    Office of Labor-Management Standards
        The fiscal year 2011 budget request for the Office of Labor-
    Management Standards (OLMS) totals $45.2 million and 269 FTE. This is
    an increase of $4 million from the fiscal year 2010 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 DOL'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 fiscal year 2011 budget
    includes an additional $2.5 million to allow OLMS to modernize an
    aging, mission-critical information technology system. This project
    will increase transparency to the public, reduce reporting burden and
    administrative costs, and improve program efficiency.
    Employee Benefits Security Administration
        DOL's Employee Benefits Security Administration (EBSA) protects the
    integrity of pensions, health plans, and other employee benefits for
    more than 150 million people. The fiscal year 2011 budget request for
    EBSA is $162 million and 941 FTE, an increase of $7.1 million (5
    percent) and 31 FTE compared to the fiscal year 2010 level. The
    additional resources will support a significantly greater demand for
    regulatory guidance, research, outreach, education, and assistance. The
    budget will improve EBSA's ability to ensure America's workers,
    retirees and their families have access to a secure retirement and
    affordable health insurance. I am very proud of the work this agency
    has done under ARRA, implementing a new appeal program related to an
    individual's appeal of the denial of his or her COBRA premium
    assistance, and responding to more than 190,000 inquiries and
    complaints from unemployed workers and their families seeking
    affordable health coverage and the COBRA subsidy; hosting more than 2.5
    million visitors to our dedicated COBRA Web site; and conducting 826
    outreach events related to the new program, including compliance
    assistance Web casts and seminars and on-site visits with workers
    facing layoff at their place of employment.
    OSHA
        I am proud that OSHA is restoring its capacity to strongly enforce
    statutory protections, provide technical support to small businesses,
    promulgate safety and health standards, strengthen the accuracy of
    safety and health statistics, and ensure that workers know about the
    hazards they face and their rights under the law. The fiscal year 2011
    budget request for OSHA is $573.1 million and 2,360 FTE, an increase of
    $14.5 million and 25 FTE more than the fiscal year 2010 level. The
    budget redirects 35 FTE from compliance assistance to enforcement and
    supports DOL's high-priority performance goal to reduce workplace
    injuries by targeting establishments and industries with the highest
    injury, illness, and fatality rates--with the goal of reducing by 2
    percent per year the number of fatalities associated with the four
    leading causes of workplace death in OSHA's jurisdiction: falls;
    electrocution; caught in or between; and struck by. The request also
    includes an additional $4 million to expand OSHA's regulatory program,
    $1 million for consultation programs focused on small businesses, and
    $1.5 million for State plans. These additional resources will support a
    vigorous enforcement presence in the Nation's workplaces and ensure
    that hard-to-reach workers know about their rights and the hazards they
    face.
    Mine Safety and Health Administration (MSHA)
        MSHA is celebrating 40 years of legislation aimed at improving
    working conditions for America's workers, and last year, MSHA recorded
    the safest year in mining in U.S. history. The fiscal year 2011 budget
    requests $360.8 million and 2,430 FTE and supports MSHA's comprehensive
    strategy to curb debilitating and potential fatal diseases caused by
    coal mine dust. The budget includes an increase of $2.3 million and 21
    FTE for the metal and nonmetal mine safety and health budget activity
    to bolster enforcement and conferencing. 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
    allow MSHA to promulgate new standards related to reducing health
    hazards associated with exposure to coal mine dust and crystalline
    silica. The request also allows MSHA to continue its work to enhance
    mine rescue and emergency operations and will support DOL's high-
    priority performance goal--which targets the most common causes of
    fatal accidents and is aimed at reducing workplace fatalities at mining
    sites by 5 percent per year based upon a rolling 5-year average.
    Office of the Solicitor
        The Office of the Solicitor (SOL) provides the legal services that
    support DOL, including DOL's enforcement programs. The fiscal year 2011
    budget includes $130.4 million and 658 FTE for SOL, an increase of $5.2
    million and 22 FTE from fiscal year 2010. This amount includes $122.5
    million in discretionary resources and $7.9 million in mandatory
    funding. The budget includes an increase of $2 million to support an
    additional 12 FTE to handle increased Mine Safety and Health
    enforcement litigation resulting from the substantial increase in the
    number of cases at the Federal Mine Safety and Health Review
    Commission. The fiscal year 2011 budget will support SOL's enforcement
    litigation, issuance of timely legal opinions, legal support for
    rulemaking, and increased efficiency through its acquisition of legal
    technology.
    Pension Benefit Guaranty Corporation
        For administrative expenses of the Pension Benefit Guaranty
    Corporation (PBGC), the fiscal year 2011 budget requests $466.3 million
    and 942 FTE. The budget includes an increase of $14.7 million for the
    PBGC's benefit determination process to cover the projected long-term
    costs of absorbing participants of several very large pension plans
    that terminated in late fiscal year 2009. In addition, $200,000 and 1
    FTE are requested to increase the capacity of the Office of Inspector
    General to support its audit, investigation, and training activities.

                    ENSURING ACCOUNTABILITY AND TRANSPARENCY

        Spending tax dollars wisely helps DOL 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 DOL. Our fiscal year 2011 budget supports those goals.
        Built around my vision of good jobs for everyone, DOL is currently
    updating its strategic plan, which will be published by September 30,
    2010 and cover fiscal years 2010-2016--a span during which the
    Department will mark its 100th anniversary of service to America's
    workers.
        Over the next several months, we will be reaching out to a broad
    range of stakeholders--including Congress--to solicit their input and
    perspective on a new strategic goal framework that will govern all
    aspects of work in DOL.
        Our strategic planning efforts dovetail nicely with President
    Obama's commitment to improve the performance of the Federal Government
    through three complementary performance management strategies. They
    are:
      --Use performance information to lead, learn, and improve outcomes;
      --Communicate performance coherently and concisely for better results
            and transparency; and
      --Strengthen problem-solving networks.
        As part of this process, DOL's fiscal year 2011 budget articulates
    five ambitious--but realistic--high-priority performance goals that we
    will strive to achieve in the next 18 to 24 months. These goals--which
    I've touched on above--offer an opportunity for DOL to achieve
    remarkable and lasting benefits for the American people. Our high-
    priority performance goals will focus the agencies on the most critical
    needs affecting the safety, health, and economic security of workers.
    We are working with our colleagues in the Office of Management and
    Budget to establish an action plan for implementation of the
    Department's high-priority performance goals--including quarterly
    milestones that we will use to gauge the progress and success of our
    implementation strategy.
    A Strengthened Commitment to Program Evaluation
        In the 2011 budget, the administration encouraged Departments to
    volunteer for a new program evaluation initiative designed to
    strengthen rigorous, objective assessments of existing Federal programs
    to help improve results and better inform funding decisions. DOL is
    proud to be one of a limited number of agencies selected to pilot this
    new approach in the fiscal year 2011 budget. The budget includes $40.3
    million to fund 5 rigorous evaluations and demonstrations of workplace
    safety enforcement and workforce development services. Most are
    demonstrations that would provide program services, coupled with
    rigorous evaluations of the strategies. While the evaluations are still
    in the design phase, we expect a substantial portion of this funding
    will go to States, workforce agencies, or for participant services. The
    five evaluations, which will be shaped and guided by DOL, working
    closely with the Office of Management and Budget and Council of
    Economic Advisors, will cover the following:
      --WIA performance measures;
      --Effects of job counseling;
      --Using linked administrative data to evaluate workforce programs;
      --Incentives for dislocated workers; and
      --Effects of OSHA inspection strategies.
        In addition, the budget includes $10 million in the departmental
    management account and $11.6 million in the training and employment
    services account to continue to pursue a robust, DOL-wide evaluation
    agenda. To effectively manage the new evaluation resources, DOL is
    establishing a Chief Evaluation Office in fiscal year 2010 to directly
    manage the Department-wide evaluation resources, and work with the
    other components of the Department to ensure a high level of rigor and
    quality in the evaluations they support.
    Workforce Data Quality Initiative
        The fiscal year 2011 budget requests $13.8 million for second-year
    funding for the DOL's Workforce Data Quality Initiative, which we are
    carrying out in partnership with the Department of Education. The
    initiative provides competitive grants to develop longitudinal data
    systems that have the capability to link workforce and education data
    collected as individuals progress through the education system and into
    the workforce. These data systems can provide valuable information to
    consumers, practitioners, policymakers, and researchers about the
    performance of education and workforce development programs. In fiscal
    year 2010, up to 12 States will receive grants to implement
    longitudinal databases over a 3-year period. The fiscal year 2011
    request will support participation of up to 12 additional States in the
    initiative.

                                 OTHER PROGRAMS

    Bureau of Labor Statistics
        Through its 21 economic programs, the Bureau of Labor Statistics
    (BLS) produces some of the Nation's most sensitive and important
    economic data. The fiscal year 2011 budget proposes $645.4 million and
    2,465 FTE for BLS, an increase of $34 million (6 percent) from the
    fiscal year 2010 level. The budget proposes several initiatives to
    modernize and improve the accuracy of BLS survey data. For example:
      --An increase of $27.3 million is requested to improve the data
            quality of the Consumer Price Index (CPI) and Consumer
            Expenditure (CE) Survey, including work to support the Census
            Bureau in its development of a supplemental poverty measure.
      --An increase of $4.9 million is included to expand the Occupational
            Employment Statistics (OES) program to annual data reporting
            from a subset of establishments, making possible year-to-year
            comparisons.
        In addition, the fiscal year 2011 budget proposes new, cost-
    effective data collection strategies that would not diminish the
    quality of the data that BLS publishes. For example:
      --A restructuring of the way in which the current employment
            statistics produces State and metropolitan area data estimates
            would save $5 million annually.
      --An alternative, model-based methodology will allow BLS to produce
            locality pay data at a lower cost. The new approach will
            eliminate the Locality Pay Surveys, ensure no reduction in the
            data quality, and save $10 million annually.
        Finally, the fiscal year 2011 budget proposes to eliminate the
    international labor comparisons program. The savings from this
    elimination and the two-cost effective data collection strategies
    mentioned above will be used to partially finance the OES, CPI, and CE
    enhancements.
        We look forward to working with Congress to implement the fiscal
    year 2011 budget strategies to improve and modernize the critically
    important economic data produced by BLS.
    Office of Disability Employment Policy (ODEP)
        Even though the majority of workers with disabilities are prepared,
    willing, and able to work, they remain a largely untapped labor pool.
    We know that people with disabilities are out of the labor force at a
    much higher rate than their counterparts without disabilities, and we
    are launching innovative partnerships to increase their employment
    opportunities. For example, along with the Office of Personnel
    Management (OPM), in April DOL is hosting a national hiring event for
    people with disabilities with participation by numerous Federal
    agencies and human resources professionals. Also, along with the
    Departments of Defense and Veterans Affairs, we have relaunched an
    improved national resource directory Web site for America's wounded
    warriors, their caregivers, other members of the veterans community,
    and employers. By visiting www.nationalresourcedirectory.gov, customers
    can now access thousands of services and resources at the national,
    State, and local levels to support recovery, rehabilitation, and
    community reintegration for veterans.
        The fiscal year 2011 budget requests $39 million and 52 FTE for
    ODEP to combat the problem by developing policy and policy strategies
    that, when implemented by ODEP's Federal, State, and local partners
    that include public and private-sector employers, will:
      --Increase physical and programmatic access for individuals with
            disabilities in WIA partner programs and at One-Stop Career
            Centers, through a partnership between ETA and the Department
            of Education.
      --Increase the employment of people with disabilities within the
            Federal Government, in partnership with OPM.
      --Make workplaces more inclusive and welcoming to both transitioning
            youth and adults with disabilities.
      --Expand access to employment supports--like technology and
            transportation. These services are crucial to the success of
            all workers in the job market, especially those with
            disabilities. ODEP will utilize ongoing partnerships with the
            Departments of Commerce, Transportation, and Education; the
            General Services Administration; the National Science
            Foundation; businesses; technology designers, developers and
            manufacturers; and the disability community to ensure that
            emerging workplace information and communication technology is
            universally available.
      --Spur new strategies for integrated employment opportunities for
            workers with disabilities within minority, women, and veteran-
            owned businesses. For example, ODEP's ``Add Us In'' initiative
            will fund a competitive grant to encourage small businesses,
            particularly minority-owned businesses, to increase the number
            of people with disabilities hired by such employers.
        The request includes $12 million for ODEP to continue its
    partnership with ETA on the Disability Employment Initiative, which
    strives to increase the capacity and accountability of the One-Stop
    Career system to provide accessible programs and services to
    individuals with disabilities. A companion request of $12 million is
    contained within the ETA budget. Our goal is to ensure that good jobs
    for everyone includes workers with disabilities.
    Bureau of International Labor Affairs (ILAB)
        One of my goals as Secretary of Labor is to help American workers
    build the foundation for a sustained recovery of the global economy,
    while contributing to a more balanced pattern of global trade in the
    future and respect for workers' rights around the world. The fiscal
    year 2011 budget requests $115 million for the ILAB, an increase of $22
    million and 10 FTE from the fiscal year 2010 level. The additional
    resources will allow ILAB to significantly expand support for
    innovative, successful programs that address root causes of violations
    of workers' rights in developing country trading partners. Of the
    increased resources, $20 million will be added to the $6.5 million in
    funding that has been provided by Congress since fiscal year 2008 for
    such workers rights initiatives. Given the challenges of the global
    economic crisis, we believe that these programs are more necessary than
    ever to prevent and address incidents of labor exploitation abroad.
        The additional $2 million increase in resources will be used to
    increase oversight, monitoring and reporting on labor rights in
    countries that have free trade agreements and trade preference programs
    with the United States and on reporting and analysis of progress
    countries are making to eliminate the worst forms of child labor. We
    anticipate adding 10 new FTE for these purposes.
        The fiscal year 2011 budget will support DOL's high-priority
    performance goal to make measurable improvements in worker rights and
    livelihoods and progress against the worst forms of child labor in at
    least eight countries by the end of fiscal year 2011. The budget will
    also continue the Bureau's longstanding commitment to building
    international relationships that improve global working conditions and
    strengthen labor standards around the world.
    Women's Bureau
        This year, the Women's Bureau will mark 90 years of work
    formulating standards and policies that promote the welfare of wage-
    earning women and advance their opportunity for fair and profitable
    employment. The Bureau's efforts to provide women in the workplace with
    the information and tools needed to obtain good jobs and economic
    security for themselves and their families is invaluable in this time
    of economic recovery.
        The Bureau's fiscal year 2011 budget includes $12.3 million and 58
    FTE, which is $700,000 above the fiscal year 2010 enacted level. This
    budget will allow the Women's Bureau to continue and increase its role
    of conducting research, outreach, and evaluations of programs and
    policies affecting working women. The budget will also allow the Bureau
    to work with the Bureau of Labor Statistics to improve data collection
    on work-family responsibilities, and support my vision of good jobs for
    everyone.

                                   CONCLUSION

        Too many Americans are ready, willing, and able to work--but cannot
    find a job. The fiscal year 2011 budget for DOL will help spur new and
    better job opportunities, foster safe workplaces that respect workers'
    rights, and ensure American workers are ready for 21st century jobs. I
    am committed to achieving the goal of Good Jobs for Everyone, and I
    look forward to working with the members of this subcommittee to make
    that vision a reality.
        Mr. Chairman, this is an overview of the programs proposed at DOL
    for fiscal year 2011.
        I am happy to respond to any questions that you may have.

        Senator Harkin. Thank you very much, Madam Secretary.
        I meant to say, before you started, and I will say it now,
    that the record will remain open, prior to your statement, for
    an opening statement by Senator Cochran or any other Senators
    who wish to submit such a statement.

                               WORKER PROTECTION

        Madam Secretary, thank you again for your great leadership.
    And let me just go over a couple things.
        The worker protection measures that you have talked about
    are heartwarming. It's about time that we recognize what has
    happened in the past. The Wage and Hour Division, which
    enforces minimum wage and overtime pay protections, lost 30
    percent of its staff between fiscal year 2000 and fiscal year
    2008. That loss of inspectors led to a drop of 36 percent in
    the number of inspections conducted by the Wage and Hour
    Division.
        In the last 8 years, 2000 to 2008, the Occupational Safety
    and Health Administration (OSHA) issued only 3 significant
    safety and health regulations, two of which were issued as a
    result of court orders. The previous administration killed the
    ergonomics regulation, which we debated here for a long time,
    and then a plan was presented to lead to reduced ergonomic
    injuries. Well, that was fine. The problem is the plan was
    never implemented. So, your budget, the 2011 budget request,
    will provide OSHA the resources it needs to address these
    regulatory issues that have been so neglected in the past.
        Also, your emphasis on green jobs--let's face it, that is
    the future. And young people have to be trained for those green
    jobs.

                        DISABILITY EMPLOYMENT INITIATIVE

        One thing I wanted to cover with you is the Disability
    Employment Initiative that we started last year, the $24
    million. And you--you're continuing that this year. I
    appreciate that. ETA and ODEP submitted a report last month on
    how they will implement this initiative. And I want to
    compliment your staff on developing a thoughtful plan that I
    believe will lead to improved services and outcomes for people
    with disabilities.
        Just as a background--in February 2010, the labor force
    participation rate of individuals with disabilities was 21.9
    percent. Think about that. People with disabilities who want to
    work, who can work, had a--well that's 78 percent, I guess,
    unemployment rate. That's just unconscionable. Right now there
    are navigators--disability program navigators for more than 40
    States.
        In the March 10 report by your inspector general which was
    titled ``Information on DOL's Efforts to Access for Persons
    with Disabilities to the One-Stop Career System,'' a couple of
    points really stand out. When One-Stop Centers connected
    individuals with disabilities with jobs, employers were just as
    likely to keep them as a nondisabled worker. However,
    individuals with disabilities were less likely to be connected
    with jobs in the first place. So, what this tells me is, we've
    got to do a better job of making these connections. Once they
    were connected with employers, the data shows that they stayed
    on the job and were kept on the job just as much as nondisabled
    people.

                         DISABILITY PROGRAM NAVIGATORS

        Now, the other thing is that the report suggests that the
    navigators, the disability program navigators, are really part
    of the answer. One-Stop Centers that had access to disability
    program navigators did a better job, according to this study,
    of connecting individuals with disabilities with jobs than
    those without navigators. So, again, that argues to make sure
    that we get more navigators out there.
        Lastly, the report noted that DOL does not have
    quantifiable goals or measures that assess DOL's progress in
    ensuring comprehensive access in One-Stops for individuals with
    disabilities. My staff tells me that DOL now is considering
    some options on this issue, so I encourage you to--hopefully,
    to get those done. And, just consider the Inspector General's
    report in asking your staff to again focus on these One-Stops
    with the navigators. How do we get more people with
    disabilities in, to connect them, and use the navigators a
    little more than what we were doing in the past to get people
    with disabilities jobs? So, I ask you to, look at that. I don't
    need a response on that.
        Secretary Solis. Yes, Mr. Chairman, I know that with the
    amount of money that you have provided us with, for both the
    ODEP and with ETA, we are going to focus in on this initiative.
    And we do realize that it is something that should be more
    comprehensive in nature. And so, we will be testing this and
    working in certain regional areas to make sure that we're doing
    the right thing, that we have the right tools available so we
    can make this happen, and then, hopefully, come back and expand
    the program.
        So, I agree with you, we should be doing more. And the
    success is really going to mean whether the quality of service
    that the navigators provide is made available to these clients,
    and, hopefully, that will result in job placement.
        I do want to tell you about an initiative that we're
    planning with OPM, with Director Berry. We have a big event
    planned with him in April for people with disabilities, to get
    them in Federal employment. And it's going to be carried out
    through our Assistant Secretary, Kathy Martinez, who I hope
    you've had an opportunity to meet with. A very dynamic
    individual. If you haven't met her, I hope we can arrange for
    that. But, our goal there is to make sure that the Federal
    Government lead by example, and that we do as much as we can to
    begin to employ individuals with disabilities even in our own
    agencies.
        Senator Harkin. Very good. I appreciate that. Look forward
    to continuing to work with you. And I look forward to meeting
    Ms. Martinez and talking with her about this.

                                   JOB CORPS

        Let me just shift to Job Corps. Again, I thank you for
    coming out to Iowa--it was a beautiful day. And I have a great
    picture of us throwing shovels of dirt in the air at the Job
    Corps Center. Because of the Recovery Act, we have somewhere
    between 200 and 250 workers there, building these new
    buildings.
        Now, there's one thing I did want to cover with you. Your
    budget suggests that you're expecting the Center to be occupied
    in mid-program year 2011. Well, that says to me around
    December. My staff has been checking with the people in Ottumwa
    and the construction people, and they say that the Center will
    be ready to serve students many months earlier, perhaps around
    May of next year. So, again, I'm wondering about that 6-month
    gap, and I'd ask you to look at that and see if we can't give
    some assurances that, as soon as that new Center's completed,
    assuming that it's done by May, that we can get students in
    there right away, rather than leaving it set until December.
    Can you inform me about that?
        Secretary Solis. Yes. Mr. Chairman, I know that this is of
    great importance to you, and was happy to be out there with
    you, with that groundbreaking ceremony that I attended.
        I wanted to just mention that we have had some changes in
    our program. We finally have a new director in the Job Corps
    program, who I hope that you'll also get a chance to meet. Her
    name is Edna Primrose, and she is also a former employee of the
    Job Corps program. This will help us by having leadership there
    that can help us with the changes and reforms we need to help
    expedite a lot of these projects. And yours is one, of course,
    of particular concern to us.
        I will work with you and your staff in any way that I can
    to see how we can try to expedite this as much as possible. I
    know that the project is currently about 43 percent complete.
    And I, like you, would like to see that we are fully
    operational by the year 2012, if not sooner, and that we have
    available at least 300 slots for students, there.
        So, I want to work with you, and obviously with Jane Oates,
    our Assistant Secretary, who you know, is also very much on top
    of--she's not--I don't think she's here with us----
        Senator Harkin. She's not here.
        Secretary Solis [continuing]. Today. But she, believe me,
    has been just unstoppable----
        Senator Harkin. Right. Right.
        Secretary Solis [continuing]. In helping us get these
    programs moving. And Job Corps is a very, very important
    program. That's one of the programs that I oversee that I have
    had the pleasure of visiting throughout the country. That's one
    of the programs that I personally make an effort to go visit.
    So, it is, I think, one of the premier programs. It's been
    around for so many years, and really doesn't get enough credit
    by the public because they do some very incredible things.

                               DENISON JOB CORPS

        And I want to welcome the students and the participants in
    your area that are here with us today.
        Senator Harkin. Right. I mentioned Kevin Fineran is also
    here, he's the guy that runs the Denison Job Corps Center; and
    Judi Giersdorf, from MDC, who runs these Job Corps Centers
    overseas. So, welcome here, and also to the students that are
    here.
        Excuse me just a minute.
        I was supposed to meet with you later, but I have to rush
    out of here. I have to go to the White House for the signing of
    the healthcare bill. So, I apologize for not being able to meet
    with you later. Now, back to the witness.
        Madam Secretary, I just want to say that, on this issue,
    assuming that we can get this up and ready to go by next May,
    if we need to make some adjustments here to ensure that we have
    the money available, I want to know that. I don't want to see
    the building sitting empty for 6 months or more if we're ready
    to go. So, if we need to make some adjustments. Please advise
    me, yes?
        Secretary Solis. I will be pleased to follow up with you
    Senator----
        Senator Harkin. Okay.
        Secretary Solis [continuing]. Mr. Chairman.
        Senator Harkin. I appreciate that very, very much.

                                      ILAB

        Oh, just one last thing before I turn it over to Senator
    Cochran: ILAB. You mentioned this is a very high priority for
    me. It's something that I've been looking after for a long,
    long time, going back to the Clinton administration. And again,
    your increase is more than welcome, because we didn't have
    those requests in the past, and we always had to add money
    here. But, I think, it's just one of the good things that our
    Nation does, is to forcefully go out and work with
    International Labor Organization and the International Program
    for the Elimination of Child Labor (IPEC).
        Believe me, I've been in a lot of these countries, I've
    looked at this--what they are doing, and I can't think of
    anything that gives a better face for America and what we're
    about in the world than trying to ensure that children are
    protected, that they aren't abused; that they aren't put in
    these unsafe work conditions. Everyplace I've been, the people
    of those countries, and their--to some extent, their
    governments--sometime we have a little problems with
    governments--but, believe me, it's just one of the really great
    things that we do. And so, I'm just glad that you're still
    focusing on that.
        I know there's always a tussle between what you might call
    ``workers' rights'' and--for the general workforce--and perhaps
    IPEC, in terms of focusing on child labor. I understand that. I
    guess I would lean more toward looking at child labor, because
    they have no one to stick up for them. No one. And sometimes to
    the extent that adult workers may have certain organizations,
    certain way--certain other things that they can go to, but
    these kids don't. So, I tend to say, ``Let's look at that
    first,'' but you can't forget about the other stuff, but I tend
    to lean more toward making sure that we put a focus on our
    anti-child-labor activities.
        Secretary Solis. Thank you, Mr. Chairman. I know that you
    have been one of our champions on this issue, in helping to
    protect children from the worst forms of child labor. And thank
    you for helping to champion some of the efforts, so that we can
    provide assistance and support through microloan programs to
    help make sure that families don't have to send their children
    into the workforce under, in some, despicable conditions. I
    know that this is something you care very deeply about. And we
    do not want to minimize or take away from our efforts in
    enforcement of child labor laws that are being broken or that
    we feel are egregious. So, we want to do everything we can to
    highlight both of those issue areas.
        And I am very delighted with the new Assistant Secretary we
    have there, Sandra Polaski, who is really helping to set a name
    for ILAB, and returning it, I think, to where it should have
    been some 10 years ago. She is also very deeply involved in
    working with other countries to help foster and expand programs
    that you helped to initiate. The Cambodia experience is the one
    that I refer to, where we get a certain sector of the garment
    industry, all the players there, to understand that we should
    all be abiding by certain standards. And once that happened,
    then markets open up, because there is a level of trust that
    helps both partners. And I think it's something that we were--
    we stepped away from in the last few years, and now, with our
    ability to do this because of additional funding, we're going
    to be able to expand that and, hopefully, share with other
    parts of the world what we can do.
        I know that Sandra Polaski has been visiting in Central
    America, and trying to see how we can gain more of our foot in
    the door in countries like El Salvador and Nicaragua and even
    going back to Jordan. So, there's some very exciting things
    happening. And I'd love to be able to sit down and talk to you
    more about it.

                          G20 LABOR MINISTER'S MEETING

        And, as you know, we are also sponsoring an upcoming G20
    Labor Minister's Meeting that'll be held here in Washington for
    the first time. There's a great deal of interest to see other
    countries sharing with us, and we sharing with them our
    practices, what we've learned, what works, but also, more
    importantly, preparing our President and other dignitaries from
    across the G20 countries to put forward a platform that will
    look at worker protection, safety, and job creation. So,
    there's a host of good things that are coming out of ILAB, even
    as small as it is. I'm very proud of the work that they're
    doing.
        Senator Harkin. Well, I'm proud of their work, too. And
    thank you for your leadership on ILAB.
        Secretary Solis. Thank you, Mr. Chairman.
        Senator Harkin. Senator Cochran.
        Senator Cochran. Mr. Chairman, thank you.
        Welcome, Madam Secretary. We appreciate your service in
    this important undertaking.

                               HURRICANE KATRINA

        When the gulf coast of Mississippi was devastated by
    Hurricane Katrina, the Job Corps Center there was destroyed.
    And it's been 2 years plus since that event, and we still don't
    have a new facility in place. But--there had been a temporary
    facility planned, but a lot of delays have caused it to lag,
    and we had heard it's now scheduled for opening in April. We're
    pleased with that. There is a permanent dormitory in the design
    phase, we're told, but it'll be 2 more years before that's
    finished.
        I would just bring this to your attention, in hopes that
    somebody can get involved and help expedite the repairs, the
    opening of a temporary facility, and, finally, the construction
    of the buildings that were destroyed by the hurricane. Do you
    have any information you could share with us about that?
        Secretary Solis. Yes. Thank you, Senator Cochran. I know
    that this is of a great deal of concern for many people,
    especially because of the area. Hurricane Katrina was so
    devastating that we're still trying to build up other
    facilities there, as well, that the Federal Government is
    targeting. But, this is something that--I know is very
    important. We do have some temporary facilities there
    available. We believe that, by June 20 of this year, we'll be
    able to include another, larger number of students that we can
    service. Right now what we're doing is bringing in, every 2
    weeks, about 20 additional students. So, by the time we hit
    June, we'll have about 168. They will be in that temporary
    facility, but we are working quickly to see that we can--as
    fast as possible, of course with your help, we'll work with you
    to see if we can get the necessary tools available to make this
    happen a lot sooner.
        I know that our goal is to get at least 300 students there.
    And I do want to inform you that we just hired a new director
    for Job Corps--Mrs. Primrose--who is a former student of our
    program--not student, but someone who actually worked in the
    program and understands the needs and how--and the attention
    that the Job Corps program really deserves.
        So, I feel very confident that we're going to be able to
    work with you and with our Assistant Secretary for ETA, Jane
    Oates, to make this possible. And I look forward to working
    with you. I, too, am very anxious to see this program in its
    more permanent facility.
        Senator Cochran. Well, thank you very much. I'm encouraged
    by what you're saying. I'm glad to know that it has your
    personal attention. We appreciate your leadership in moving the
    construction forward.

                  OFFICE OF LABOR MANAGEMENT STANDARDS (OLMS)

        One other thing that has been brought to my attention, in
    preparation for the hearing, and that is that the enforcement
    of labor standards is in the hands of the OLMS. And there's
    some question about whether or not funds have been requested in
    an amount that will permit this office to carry out its
    responsibilities. I understand that financial disclosure forms
    are filed by unions, with this office. And is there any effort
    to cut down on the oversight, or any of the enforcement
    activities, of OLMS, as reflected in these low levels of
    funding requests?
        Secretary Solis. Senator Cochran, I'm glad you asked me
    that question. I know the last time that I was here before the
    subcommittee, I stressed that we would do everything in our
    power to make sure that we level the playing field, that we
    work to be more accountable and transparent with union members,
    and also making sure that we could disclose information. And
    I'm actually happy to say that, with our commitment in the
    fiscal year 2011 budget, we're actually increasing the amount
    of money--$3.8 million--for OLMS. Much of that will go into
    technology so that we can make it easier for reporting to be
    disclosed on forms that will be accessible through electronic
    means. And that's something that hasn't been done as
    extensively as we would like. So, we'll actually be able to
    increase, from 3 to 12, the number of public forms that will be
    electronically submitted. So, there will be more disclosure.
        What we're trying to also do is really focus in on those
    egregious cases that come about. I want to report that criminal
    investigations are up for 2009. In 2008, it was 393; 2009, it
    was 404. Convictions, 103 for 2008; for 2009, 120. So, I can
    tell you that we are working very hard to make sure that we
    investigate those places and--necessary reporting requirements
    have to be adhered to, and we're trying to make it easier for
    in OLMS to make sure that we get the right information, that we
    don't overburden the system with unnecessary information, but
    that it is clear, transparent, and available for union members
    to see, as well.

                               PREPARED STATEMENT

        Senator Cochran. Thank you very much. And, we may have some
    other questions that we may submit for the record, Mr.
    Chairman.
        Senator Harkin. Absolutely.
        Senator Cochran. Thank you.
        [The statement follows:]
                   Prepared Statement of Senator Thad Cochran
        Mr. Chairman, thank you for calling this hearing to discuss the
    fiscal year 2011 budget for the Department of Labor.
        I want to welcome Secretary Solis to her second appearance before
    this subcommittee and look forward to her testimony.
        Madam Secretary, I want to commend you for your continued support
    of the Youthbuild Program. With funding from your department, the
    Corporation for National and Community Service and private foundations,
    amazing work has been done in the Gulf Coast region. Young people from
    the Youthbuild Americorps Gulf Coast Program have rebuilt more than 150
    homes damaged by Hurricane Katrina. This program has given out-of-
    school, out-of-work youth the opportunity to obtain their general
    education diploma, gain vocational training, and get paid while
    learning. We look forward to working with you to continue this
    important program.
        Once again, I thank you Mr. Chairman for calling this important
    hearing.

        Secretary Solis. Thank you, Senator.
        Senator Cochran. Thank you, Madam Secretary.
        Senator Harkin. Senator Specter.

                       STATEMENT OF SENATOR ARLEN SPECTER

        Senator Specter. Thank you, Mr. Chairman.
        Madam Secretary, thank you for taking on this important
    job. With all of the excitement in the House of Representatives
    in the last few days, do you ever miss it?
        Secretary Solis. I feel even more connected today.
        Senator Specter. Well, you left your key position in the
    House; and with all of the excitement and activity, I thought
    you might have some thought about that line, especially a
    couple of days after the big event.

                              DECREASE IN FUNDING

        Madam Secretary, I note that there has been a decrease in
    funding for the DOL, some $300 million from the 2010 level. And
    with the enormous responsibilities you have for occupational
    safety, health, and mine safety, and Job Corps, seems to be
    hard for you to stretch the dollars.

                VETERANS EMPLOYMENT AND TRAINING SERVICE (VETS)

        There are a couple of specific items I would like your
    comment about. And one relates to the VETS. The funding there,
    as I see the briefing notes, will allow for employment and
    training assistance to some 25,000 homeless veterans. And that
    seems to me to be a relatively small number of the veterans who
    are returning from very difficult duty in Iraq, Afghanistan,
    and other places. And how many--if you know, or provide it
    later--of the veterans who could qualify for that kind of
    employment and training service are there, beyond the 25,000?
        Secretary Solis. Senator Specter, we're looking at the
    issue of employment placement through VETS, something that I
    think has been put aside in the past few years.
        We have a very dynamic Assistant Secretary there. Ray
    Jefferson, who you may know, is a West Point graduate, also
    served in, I believe, Afghanistan, and brings to the Department
    a real enthusiasm, as well as strategic direction of where we
    need to go with helping our veterans that are coming home. This
    is a very serious problem and concern for all of us. I know
    that what we have done is try to increase the budget so we not
    only look at employment opportunities, but that we engage with
    private partners, such as the Chamber of Commerce, for creating
    these partnerships so that we can easily place some of our
    returning veterans in business and job opportunities throughout
    the country.
        This is something that I believe has to happen now, because
    there's a high rate of unemployment amongst our returning young
    veterans, in particular--the rate is very, very high. I realize
    that our budget is somewhat limited, but we're testing some new
    theories, so to speak. One of them is the TAP program, which
    will help those veterans that are coming home be able to
    reintegrate and understand what services are immediately
    available. We're working in partnership with the Department of
    Defense on this, but it's something that I don't think has
    really been fully developed. And so, we're taking a shot at it,
    because I think it's something that's very important to help
    provide even further assistance so that veterans and their
    family members, their spouses, also have the ability to draw
    down information and services that they're eligible for.
        You wouldn't believe how many people I've come across, as a
    former member in my district, visiting some of these locations
    where veterans are returning, and they're kind of rushed
    through in a--maybe a 1-day event where they're given
    information, that may not really be digested well that one day,
    because they're coming home, they're thinking about other
    things. We believe that services have to be--have to be carried
    out in a manner that's actually going to be effective. So, we
    want to be able to monitor what we're doing; we want to be
    accountable; we want to make sure that the right services are
    happening for our veterans, and especially homeless veterans,
    as well as female veterans. And that's why we're making
    available an amount of $5 million to start working with female
    veterans who are coming back and really struggling, many who
    have experienced sexual assault and may become homeless, as
    well.
        I hope we can work with you on----
        Senator Specter. Madam Secretary, I'd appreciate it if
    you'd take a look at the total number of veterans in that
    category who need that service. Perhaps this is something where
    there could be some assistance from the Veterans
    Administration. I serve on the Veterans Committee, used to
    chair it. And they have a--an extensive budget. And perhaps we
    could have some coordination there, if, in fact, there is a
    large number, beyond what you can accommodate within your
    budget.
        Secretary Solis. Senator, I'd be happy to work with you on
    that. Obviously, the Veterans Administration has a much larger
    budget, as you state, than we do. And I would definitely like
    to work with Cabinet member Shinseki. We've had discussions
    about this, and it would--I would very much like to work with
    you, and, of course, the Chairman, on this.
        [The information follows:]

        The veterans' courts got their start at homeless veterans stand-
    down events when organizers decided to provide homeless veterans with
    an opportunity to address legal barriers such as DUIs, misdemeanors,
    child support and other legal-related issues which precluded many
    homeless veterans from seeking reintegration into the mainstream. This
    concept has been expanded by the Department of Veterans Affairs (VA) to
    include issues related to mental health and drug courts.
        Veterans' Employment and Training Service (VETS) has supported
    homeless veterans stand-down events through not-for-profits who serve
    homeless veterans. This support includes local veterans employment
    representatives and/or Disabled Veterans Outreach Program specialists
    being available to address employment and training needs of homeless
    veterans.
        Our recent Solicitation for Grant Application (SGA) focusing on
    incarcerated veterans has a component to address issues that impact on
    the re-entry of veterans from Federal, State, and local correctional
    facilities. In an effort to ensure that veterans being served by these
    grants receive access to a wide-range of services, the SGA contains
    language which requires partnership with the VA including collaboration
    with medical centers and especially the VA re-entry specialists and
    justice outreach coordinators.
        VETS' staff recently attended a national VA conference to assist in
    the training of justice outreach coordinators to ensure that a linkage
    with local workforce staff occurs to provide employment and training
    opportunities for veterans who are coming out of incarceration and/or
    jail.
        VETS' staff also attended a defendant/offender workforce
    development conference to discuss interaction with the criminal justice
    system in partnership with the VA with correctional institutes and
    parole and probation officers.
        We announced on April 26, 2010, a grant competition under 38 U.S.C.
    2021, which provides employment assistance to Veterans who are homeless
    and this year we have targeted homeless female veterans and veterans
    with families. Additional information may be found on our Web site at
    http://www.dol.gov/vets
        Lastly, VETS is planning a postaward conference for all of their
    Homeless Veterans Reintegration Program and Incarcerated Veterans'
    Transition Program service providers and will devote time to discuss
    the role of the Department of Labor in assisting veterans who are
    leaving a Federal, State, or local jail as well as working with the
    VA's justice outreach coordinators to provide a plan for those veterans
    interacting with the veterans' courts.

                                  MINE SAFETY

        Senator Specter. The issue of mine safety is a gigantic
    one. We tend to downplay it until there is a tragedy, and then
    we're all up in arms about it. In the MINER Act of 2006, there
    was a requirement for communications gear. An interesting
    article in the Charleston Gazette reported on a lack of
    wireless communications in some--only 34 of the Nation's 415
    active underground mines possessed fully functional wireless
    underground communications capabilities. Would you take a look
    at that issue and let us know if that figure is accurate, and,
    if so, what the plans are to cover the balance of those
    facilities?
        Secretary Solis. Yes, Senator Specter. I am intrigued by
    the kind of work that is done by our Mine Safety and Health
    Administration (MSHA) programs now, and had the opportunity
    last year to go down and actually visit one of our mines in
    Virginia, and saw the equipment--some of the more premier
    equipment that's available for communication. It was explained
    to me how that works, if there are disasters that occur, what
    backup plans are necessary. And they're very costly, on both
    sides--for us to do the inspection, in terms of our staff, but
    also for the employer. So, there is a need for us to focus more
    on what mines are not doing, because of their inability or not
    knowing that these safety precautions need to be put in place.
    I would certainly want to work with you. I know this is
    something that our new Assistant Secretary, Joe Main, takes
    seriously about ways to improve our work in MSHA-- and is
    somebody who has a great deal of respect, I think, from both
    sides--management and labor.
        [The information follows:]

               Underground Communications and Tracking Equipment

        As of April 2, 2010, there were 414 active underground coal mines
    and 75 active nonproducing mines required to have electrical
    communications and tracking (C&T) systems within an approved emergency
    response plan (ERP). Of those 489 mines, 441, or 90 percent, had an
    approved ERP that included provisions for a C&T system.
        As of March 31, 2010, 58 mines had C&T equipment completely
    installed and operational in both the outby and inby section loading
    points. An additional 154 mines were in process of installing C&T
    systems.
        The remaining 229 mines with an approved ERP [441-(58 + 154)] were
    awaiting delivery of system components from manufacturers or suppliers.
    Mine Safety and Health Administration (MSHA) supplemental questions and
    answers on Program Policy Letter No. P09-V01 states that mine operators
    must provide to MSHA, within 15 days of plan approval, a purchase order
    for the communication and tracking systems that will be installed in
    accordance with an approved ERP. Absent factors beyond the operator's
    control, the system(s) must be installed within 3 months of the
    delivery date specified in the bona fide purchase order. As of April 2,
    2010, operators with approved plans had purchase orders with delivery
    dates as late as 2011.
        MSHA's districts continue their work with the remaining 48 mines
    that do not yet have an approved ERP to develop an acceptable plan. In
    instances where MSHA and the operator cannot come to agreement on an
    approved plan, MSHA is working with the Office of the Solicitor to take
    legal action to bring the operator into compliance with the act.

        Senator Specter. One final comment. You and I have talked
    about the possibility of your coming to Pennsylvania. It's not
    as a far as Iowa or Mississippi or Rhode Island. The work that
    you're doing has tremendous impact, generally, but especially
    on the big cities, on the Job Corps, so many unemployed
    minorities with so many difficulties. So, we'll pursue that, on
    the staff level.
        Thank you very much, Madam Secretary.
        Secretary Solis. I look forward to that visit. Thank you--
    --
        Senator Specter. Thank you.
        Secretary Solis [continuing]. Senator. Thank you.
        Senator Harkin. Senator Reed.

                         STATEMENT OF SENATOR JACK REED

        Senator Reed. Thank you very much, Mr. Chairman.
        And thank you, Madam Secretary, for your work and for
    joining us today.
        One of the consequences of this severe financial crisis is
    more than 30 States have borrowed up to $35 billion from the
    Federal Government to continue paying their regular
    unemployment compensation benefits. And as some States look for
    ways to pay back their loans and balance their budgets, they're
    at least contemplating raising taxes on employers, which would
    be, essentially, counterproductive, in the sense that we are
    doing all we can to encourage hiring by lowering the cost of
    employees. The States in this situation would be pushing
    against us. So, it leads to the obvious question of what we can
    do to help these States.
        In the 1980s, there was some--both permanent and some
    temporary assistance offered to States who were in danger of
    credit reduction when they don't repay their loans. I'm
    wondering what you and the Department are thinking about in
    this context, and what, together, we can do to provide some
    assistance.
        Secretary Solis. Thank you, Senator Reed. And I also want
    to thank you for the opportunity to visit your State and your
    Job Corps last year.
        Senator Reed. Thank you.
        Secretary Solis. I will say that this is a very serious
    recession that I still think we are in. And I know that many of
    our States, including the one that I'm from, California, have
    seen just unprecedented levels of use of the UI Trust Fund. And
    yes, we do have to do something. And I'd be happy to work with
    you to figure out how we can try to fix this, because many--too
    many people are suffering. And it isn't enough just to think
    about this in terms of this short-term crisis, but to think,
    long-term, how we can remedy this.
        So, I'm looking and anxious to hear what options you might
    have, so that I can work with you and take back to--take back
    to our administration--how we can shorten the time that people
    get benefits and help the systems work better. There are major
    problems with the infrastructure, the delivery system itself,
    the fact that many--even State employees are being furloughed
    in this area, and that aren't even able to expedite and process
    some of these applications. And then, to further add to it, the
    fact that many of our States aren't creating or generating any
    revenue to pay in, so our businesses aren't able to participate
    as they, maybe, would have. These are not normal times, and it
    requires some new thinking. And I look forward to working with
    you. I hope that's sufficient.

                EXTENDING TEMPORARY WAIVER OF INTEREST PAYMENTS

        Senator Reed. Well, thank you very much, Madam Secretary. I
    think we understand the problem, and now we have to really roll
    up our sleeves and see what we can do, specifically. And not
    only in terms of the efficiencies you outlined, but avoiding
    the contradiction of Federal policy lowering the cost of
    employment and State policy raising the cost of employment.
        There's another aspect of this issue, and that is: In the
    Recovery Act, there was a temporary waiver of interest payments
    and accrual of interest on Federal advances to the unemployment
    funds through the end of this year. What are your thoughts
    about extending those provisions for the following year?
        Secretary Solis. I would want to work with you closely on
    that to see what we can come up with. I know that the
    administration is looking at different packages right now. And
    I know you've been very helpful, with some of your ideas. So, I
    look forward to working with you. I think you have a great deal
    of experience in this area that can help us. So, I'm willing to
    work with you on that.
        Senator Reed. Well, thank you. I think we all recognize
    that your advocacy within the Cabinet for this--these programs
    and these policies is absolutely critical. So, if you work
    inside, we'll try to work outside, I guess. And we'll work
    together.

                         NEW WORKFORCE INNOVATION FUND

        One of the aspects of the President's budget is the $108
    million for the new Workforce Innovation Fund, including
    expanding ``learn and earn'' strategies, like apprentice
    programs. And it raises a question, in terms of accelerating
    apprentice programs that are incorporating these programs in
    Federal construction contracts. To be specific, we've been
    working with the Navy, in Newport, and trying to have them
    recognize this one factor award in their contract award, those
    companies who participate in apprentice programs, as a way to
    incentivize them to develop apprentices. And I wonder,
    generally, across the board, what would be your attitude toward
    a--including this factor--apprenticeship programs--in the award
    of Federal contracts.
        Secretary Solis. Well, Senator, as you know, we have--
    through the ETA program, we run our own apprenticeship program,
    as well--a registered program there. And I know that, in the
    course of this recession, we've really found that some of the
    best programs are run through these various apprenticeship
    programs, where you have private industry as well as labor
    working together, on-the-job training. And the masterful skill
    and training and certification that's gained by it, I think,
    makes these individuals much more marketable than if they
    would've gone through another program. It is--they're more
    costly, they're limited in reach, in terms of how many people
    can be a part of this. And I'm looking at ways of how we can
    expand it. So, I'm actually very favorably looking at how we
    can do that. So, that's another area that I would like to work
    with you on.
        Through our WIA programs, if I can just mention, we have
    made it a point to also provide assistance to pre-
    apprenticeship programs, because there's a lot of folks that
    want to get into apprenticeship programs, but aren't prepped up
    enough to understand the requirements and the rigors, because
    these programs are very highly technical in skill and skill
    development and the skill sets that must be acquired. And I can
    see where, if we're going to try to push a new--a whole new
    generation of people to get into these jobs, we're going to
    need to have an expansive way of allowing for access to reach
    more people. So, that's something that we're also exploring,
    but I definitely want to see more opportunity available so that
    we can have apprenticeship programs in some of our major
    Federal projects that we undertake.
        So, I very much agree with your statement.
        Senator Reed. Thank you, Madam Secretary.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you all very much.

                            SUMMER YOUTH EMPLOYMENT

        I just had one follow-up question, Madam Secretary, and it
    had to do with summer youth employment. The Recovery Act
    provided $1.2 billion, we had 300,000 young Americans. I met a
    lot of them last summer, in my own home State, and we had a
    meeting March 9, Senator Murray had an amendment that would
    have provided $1.5 billion in supplemental funding for DOL's
    youth for the summer employment program, but it failed, on a
    budget point of order, even though we had 55 votes in favor of
    it. But, I'm just wondering how you're viewing the summer
    coming up. And what can we do with whatever funds you might
    have? And we're going to have a lot of kids out there that
    could be working this summer, so how do you see that unfolding?
    I mean, we're now in March already, almost April.
        Secretary Solis. Mr. Chairman, I know that this is an issue
    that both Senator Murray and yourself have been championing for
    some time. I, too, was disappointed that the proposed amendment
    was not passed. I'm ready to work with you and other Members of
    the Senate to see how we can get additional funds. I know the
    President is committed to seeing this program funded in a way
    that we can, hopefully, bring in another 350,000 students to
    participate. Last year, we were at 318,000. We doubled the
    number of young people that we thought could be involved in the
    program.
        We know it works. It is something very important. I know
    the House has, I believe, a measure that they're proposing that
    doesn't go quite as far. I understand that under a Federal
    Emergency Management Agency supplemental, there will be some
    amount of money--$600 million, I believe--which, again, isn't
    quite the amount that Senator Murray and you were pushing. So,
    I would want to work with you to see how quickly we can get
    this done, because people have to plan now, at the local level,
    to start hiring up and get this program in place. We were very
    fortunate that, after 10 years, we were able to get this
    program somewhat up on its feet. But, we want to expand it and
    make sure that it is available for all those that need this
    program. And I agree, when you see these students in these
    programs, some of them are just amazing--the work that they
    gain, the experience they gain, but also the work ethic that
    inspires them to want to continue to go to school, but also
    hold down a job.
        Senator Harkin. I can't tell you how many I talked to last
    summer that--you know, were thrilled with what they were doing.
    And many of them are just saving their money to go to college.
    I mean, this is some of the money that helps them get through
    school; plus giving them, as you said, job training and work
    experience, that type of thing; plus helping our economy.

             SUPPLEMENTAL APPROPRIATION FOR SUMMER YOUTH EMPLOYMENT

        So, I'm hopeful that sometime soon the Congress will be
    able to appropriate some money for summer youth employment. You
    just don't have it in your budget. I mean, there's no way we
    can hire 300,000 young people this summer with what you have.
    It has to be a supplemental appropriation. And, as you point
    out, we're now coming to April--we've got a couple weeks off
    for Easter break--we come back, so if we're going to do it, we
    have to do it pretty soon, in order to get the money out, make
    sure the youth get employed this summer.
        I can't think of a more important thing to do in the
    immediate timeframe than that.
        Secretary Solis. Senator, thank you. I know this is one of
    those programs where the money goes out quickly, and it is
    either spent or it's saved. But, in most cases, some of the
    students that I met with were actually helping to supplement
    their income. I met with some students in Puerto Rico that were
    working on conservation projects along the beach. And you know
    how tourism is very important to that part of the country. That
    money, some of the students were telling me, was used to help
    their families pay rent, because the unemployment rate there is
    even double. So, it's amazing what young people will do when
    there is an opportunity made available through these programs.
        Senator Harkin. Sure.
        Well, Madam Secretary, thank you again, very much for
    coming up early.
        Secretary Solis. Thank you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. The subcommittee will have a number of
    questions for the record. And the record will be open for 10
    days for Members to submit additional questions.
        Thank you very much.
        [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

                  EMPLOYMENT AND TRAINING ADMINISTRATION (ETA)

        Question. ETA has proposed $107,651,000 and appropriations language
    to establish a new Workforce Innovation Fund (WIF). ETA is planning to
    use not more than 5 percent of an allocation under the proposed adult
    and dislocated worker WIF for rigorous evaluation of all project funded
    under the demonstration phase of the program.
        How many demonstration grants would ETA award under the program?
    What would the evidentiary standard be for replication projects using
    ``promising or proven'' projects, and how many replication grants would
    be funded at the requested amount?
        Answer. The Innovation Fund will test and replicate innovative
    strategies for training and re-employment services that respond to the
    current and future needs of workers and the economy. The mix of
    demonstration and replication grants, as well as standards for
    replicating promising or proven program practices, will be developed as
    part of the Solicitation for Grant Applications (SGA). The number of
    grants will depend on the size, scope, and design of the grants
    awarded, and will be influenced by the innovative concepts and
    promising practices proposed by applicants to address issue areas such
    as ``learn and earn'' models, linkages with economic development,
    supporting regional and sectoral collaboration, reaching underserved
    populations, working across programs to provide comprehensive services,
    and enhancing technology to increase the quality or expand the scope of
    services provided.
        WIF also will allow applicants to propose promising practices or
    approaches they wish to replicate and build evidence that the approach
    is effective or can be taken to a larger scale. The SGA will include
    response criteria for applicants to address when proposing to replicate
    ``promising or proven'' approaches, which will include evidence that
    the approach produces positive performance outcomes or has significant
    impacts, and other evidence supporting the rationale for replication.
        I look forward to working with the subcommittee on this important
    endeavor and providing further information about our progress and
    activities.
        Both the American Recovery and Reinvestment Act (ARRA) and the
    fiscal year 2010 Department of Labor Appropriations Act provided local
    Workforce Investment Boards (WIB) 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. The fiscal year 2011
    budget continues this authority.
        Question. How has the Department of Labor (DOL) monitored and
    evaluated the use of this authority? Is it a cost-effective mechanism
    for providing support for training at the local level?
        Answer. DOL monitors the use of the authority to contract with
    institutions of higher education or other eligible training providers
    under ARRA through our standard desk and on-site grant reviews and
    other oversight activities. ETA does not collect such information
    through its approved data collection systems. This authority was also
    included as part of DOL's fiscal year 2010 appropriation for use during
    the program year starting July 1, 2010. Use of the authority varies by
    State, depending on need and program design. However, many local WIBs
    are using this authority to add flexibility to their program design. In
    a recession, it is common that the number of students attending
    training greatly increases and creates a shortage in available training
    for in-demand occupations. In such cases, contracted training can be
    useful in expanding opportunities and consumer choice.
        The use of contracts to provide training capacity for One-Stop
    Career Center customers gives local areas flexibility beyond Individual
    Training Accounts (ITAs) to meet customer needs. Contracting authority
    allows local areas to cover a larger range of costs than ITAs, allowing
    local areas to develop new curricula and expand training offerings to
    meet the skill needs of growing industry sectors. Local areas indicate
    that contracted training that expands existing program capacity by
    funding seats during off-hours or at alternate sites can be less
    expensive than the cost of the class in the traditional setting. In
    cases where contracted training is more expensive on a per-student
    basis than an ITA slot, local areas report that the costs of forgoing
    or delaying training of WIA participants due to limited capacity exceed
    the additional monetary cost of offering these courses via contract.
    Increasing training capacity can help low-income adults and dislocated
    workers enter the workforce more quickly. Therefore, we believe that
    this authority can offer a cost-effective, customer-driven alternative
    for providing support for training at the local level.
        The fiscal year 2011 request for youth activities includes
    $153,750,000 and appropriations language creating a Youth Innovation
    Fund (YIF). The fund would support grants for summer and year-round
    employment opportunities, and Work Experience Plus grants.
        Question. How many of each type of grant will be awarded at the
    budget request amount? What would the evidentiary standard be for
    projects seeking to replicate program practices that are proven
    successful?
        Answer. At the budget request amount, ETA anticipates awarding 30
    to 50 grants to support summer and year-round employment opportunities
    and between 18 and 25 Work Experience Plus grants. Similar to the WIF,
    the mix of demonstration and replication grants, as well as standards
    for replicating promising or proven program practices, will be
    developed for the YIF as part of the SGA. The number of grants will
    depend on the size, scope, and design of specific projects awarded
    funding, and will be influenced by the innovative concepts and
    promising practices proposed by applicants, including strategies to
    create new partnerships with the private sector, organized labor,
    public sector, and community organizations, and to test new approaches
    to delivering work and learning experiences and related services to
    improve outcomes for underserved populations, such as out-of-school
    youth, youth with disabilities, or homeless youth. The SGA will include
    response criteria asking applicants to provide evidence that the
    proposed approach produces or has the potential to produce positive
    impacts on educational and employment outcomes.
        The fiscal year 2011 congressional budget justification indicates
    that ETA will continue its focus on developing collaborative systems at
    the Federal, State, and local level for serving the youth most in need.
    ETA recently issued guidance on innovative contracting strategies to
    better serve youth most in need.
        Question. Have you seen any changes made in State and local
    practices related to the strategies outlined in this contracting
    guidance? Have your efforts on coordination identified other barriers
    to using resources effectively to serve youth most in need? If so, what
    are they and what actions are planned by DOL and Federal partners to
    address them?
        Answer. The contracting guidance was released in February 2010 and
    it is too early to see any changes made in State and local practices
    related to structuring contracts to better serve the youth most in
    need. In order to encourage collaboration across systems to more
    effectively serve the youth most in need, ETA and the Administration
    for Children and Families in the Department of Health and Human
    Services issued a joint letter in January 2010 encouraging the
    workforce system to partner with Temporary Assistance for Needy
    Families (TANF) agencies to create subsidized employment opportunities,
    including summer jobs, using ARRA TANF emergency funding. ETA also
    issued Training and Employment Notice 24-09 to highlight this
    partnership. Since January, a number of States have started to develop
    the type of partnerships outlined in the joint letter.
        ETA was planning to complete 50-75 on-site monitoring reviews of
    One-Stop Centers in program year 2010.
        Question. What has this monitoring found on the issues of access
    and services for individuals with disabilities, including specifically
    physical and programmatic barriers? How do these findings compare to
    such reviews in program year 2009? How many reviews are planned for
    program year 2011?
        Answer. ETA is currently in the last quarter of program year 2009,
    and entering program year 2010 on July 1, 2010. Program year 2011 will
    begin July 1, 2011.
        In early program year 2009, in preparation for the addition of ARRA
    funding, ETA visited all 53 States and territories and 156 local areas
    for a total of 209 visits to determine their readiness for ARRA
    activities. These were not monitoring reviews, but integration of
    programs and accessibility of program services were examined.
        In regular program compliance monitoring visits, ETA has monitored
    53 States and territories and at least 114 One-Stop Career Centers in
    program year 2009. The small number of compliance issues identified
    included the weight of a One-Stop entrance door in Delaware and a
    Washington, DC youth classroom on the second floor without elevator
    access. Both areas resolved the problem. Most regions report no issues,
    and state that centers have been successful in building up the training
    and resources for staff, as well as additional resources and
    relationships with employers for individuals with disabilities. In
    region 6 for example, California, Arizona, Idaho, and Hawaii have been
    pursuing the purchase of additional assistive technology and upgrades
    to existing assistive technology for their comprehensive One-Stop
    Career Centers. The States of California and Arizona have also
    increased sponsorship and coordination efforts to promote the
    availability of accessible programs and services for people with
    disabilities, and have utilized a portion of their Wagner-Peyser ARRA
    funds to increase awareness of service accessibility for people with
    disabilities. Whenever issues of compliance arise the regional office
    issues corrective action plans and provides technical assistance, and
    ETA advises States to closely monitor implementation of the corrective
    action plans.
        In addition, Office of Disability Employment and ETA will conduct a
    separate independent survey of the physical, programmatic, and
    communications accessibility of the One-Stop Career Center system in
    the fall of 2011. DOL anticipates that a number of large, medium, and
    small comprehensive One-Stop Career Centers will be selected across
    several States. A full survey of accessibility will be conducted in the
    fall of 2011 that includes review of WIB policies and procedures
    relative to the availability of intensive and training services for
    individuals with disabilities.
        Work plans for monitoring have not yet been formulated for program
    year 2011, which begins July 1, 2011. However, we anticipate a similar
    number of local reviews in program year 2010 and 2011 as were conducted
    in 2009.
        The 2011 request for Job Corps operations is $1,572,253,000, a
    decrease of $1,762,000 below the 2010 level. The budget indicates that
    ``The budget requires that efficiencies within Job Corps operations are
    pursued.''
        Question. Please describe the efficiencies that Job Corps has
    achieved in recent years and what may be pursued in 2011 that will not
    compromise the outcome goals of the program.
        Answer. The Office of Job Corps routinely seeks program
    efficiencies that produce a cost savings without compromising the
    effectiveness of service to its students. As part of the 2011 budget,
    the program is pursuing a reform agenda to identify additional
    operational efficiencies and improve student outcomes.
        One of the operational efficiencies Job Corps is pursuing is to
    reduce ever-increasing utility and fuel costs. The activities Job Corps
    plans to conduct include: reducing the program's General Services
    Administration vehicle fleet; replacing traditional vehicles with
    alternative energy-efficient electric vehicles; and ARRA-funded energy
    efficient upgrades that will reduce utilities costs at Job Corps center
    facilities. To complement these efforts, we have implemented a
    nationwide energy conservation campaign, funded by ARRA, which promotes
    the adoption of ``green'' practices by students and staff. Further, our
    new Job Corps centers are being built to meet Leadership in Energy and
    Environmental Design specifications and will be state-of-the-art,
    energy-efficient facilities.
        Job Corps also is working to maximize centers' slot capacity
    utilization, which includes increasing student retention. The program
    anticipates an increase in students' average length of stay as a result
    of our rigorous career technical training system that includes
    industry-focused foundations courses for new students and the
    incorporation of industry-recognized certifications. Under this system,
    students need to remain in the program longer to complete program
    requirements and this increased retention will reduce costly student
    turnover.
        Finally, Job Corps is exploring ways to decrease the cost of large-
    scale, on-center services, such as basic medical care and prescription
    drugs, without compromising the quality or provision of these services
    to students. The program also will evaluate its discretionary national
    office support contracts for possible reduction or conversion to
    Federal staff.
        Question. What connections have been made across systems to provide
    support to Job Corps students eligible for services through systems,
    such as Medicaid?
        Answer. As part of the admissions process, and upon conditional
    enrollment, students are asked to provide verification of any private
    insurance or Medicaid coverage. If the applicant has no coverage,
    center staff assists the applicant in applying for either State medical
    coverage and/or Medicaid.
        The Job Corps program also encourages all centers to establish
    working relationships with their local health departments and community
    health organizations. This allows the program to augment its available
    resources to deliver a wider array of services.
        Job Corps Health and Wellness Desk Reference Guides developed for
    center health and wellness managers, center mental health consultants,
    disability coordinators, and center physicians provide suggestions and
    examples for cost-saving strategies by developing relationships with
    community resources (e.g., check for agencies that may be receiving
    grant money to provide a range of services--from mental health to
    family planning to nutrition planning; contact local health department
    and review what services are available at no cost to Job Corps
    students; review with local hospital and associated clinics their
    policies on providing free/low-cost services to economically
    disadvantaged patients).
        Technical Assistance Guides (TAGs) provide guidance regarding
    community connections (e.g., TEAP TAG encourages centers to establish
    community connections that support relapse prevention efforts and
    provides examples (e.g., self-help groups). The Family Planning TAG
    encourages centers to supplement program components not available on
    center with free or low-cost community resources and provides examples.
    The Immunization TAG encourages centers to contact their State/local
    health departments to determine vaccine availability under the Vaccines
    for Children (VFC) program which provides free vaccines to children who
    are on Medicaid, are without insurance or underinsured, or are Indian/
    Alaskan Natives).
        Regional office staff monitors the health and wellness programs as
    part of their regular monitoring of the centers.
        The Advisory Committee on Job Corps made a number of
    recommendations about improving services to students with disabilities
    through Job Corps centers.
        Question. What actions is ETA taking or planning to take to help
    improve such services? How does the 2011 budget support such these
    actions?
        Answer. The Job Corps Advisory Committee made a number of
    recommendations to improve Job Corps' handling of students with
    disabilities. We have already pursued several recommendations, and seek
    to continue their implementation as part of our 2011 budget request.
        One recommendation was to improve center staffs education about
    disabilities. The program responded by dramatically increasing its
    training opportunities for center staff through platform trainings,
    webinars, the provision of on-site technical assistance, and the
    deployment of information toolkits through the Job Corps Disability Web
    site.
        The Advisory Committee also suggested that centers hire special
    education teachers to assist students with disabilities. Job Corps
    centers are encouraged to employ these teachers, whenever possible. The
    Office of Job Corps will continue to work to increase the number of
    special education teachers at our centers.
        In keeping with the Advisory Committee's recommendation, Regional
    Disability Specialists have been employed by Job Corps and support
    centers in their respective regions. These specialists serve as
    technical experts and provide center staff with assistance in the area
    of disability accommodations and education.
        Another committee recommendation was to improve employer outreach
    for the hiring of students with disabilities. Job Corps is conducting
    webinars for placement staff on communicating with employers about the
    benefits of hiring students with disabilities.
        We also created tools and identified resources that would improve
    students' self-advocacy skills, enabling them to become knowledgeable
    of and confident in their rights. Additionally, Job Corps has expanded
    its strategic alliances with other groups to better leverage and
    augment the disability-related services it can provide.
        The budget request indicates that funds have been requested for a
    ``compensation adjustment'' for professional Job Corps staff and
    further indicates that staff compensation is a part of ``program
    reform.''
        Question. Can you describe what ``program reform'' means and how
    the 2011 budget will be used to support to support this effort?
        Answer. The Office of Job Corps' agenda for program reform will
    include identification of program inefficiencies that can be resolved
    to produce savings, such as reducing fuel and utility costs, maximizing
    centers' slot capacity and improving student retention, and taking
    advantage of economies of scale for targeted on center services.
        Job Corps is also planning to conduct an assessment of its
    operational structure, with a particular focus on center performance.
    The review will examine variations in the way the program model is
    being implemented across centers and identify best practices at high-
    performing centers that can and should be replicated across the Job
    Corps system. In response to the findings, Job Corps will develop
    aggressive improvement plans to assist lower performing centers. The
    administration has begun the process of procuring an outside evaluator
    to conduct this review.
        To maintain high-quality instruction, one specific challenge that
    Job Corps faces as part of reform is staff compensation levels for our
    academic and career technical training instructors. Job Corps analyzed
    a sample of academic and career technical instructor salaries in April
    2009. The sample was representative of instructor salaries at
    approximately 30 percent of centers operated by private or nonprofit
    contractors. Selected centers were located across all six regions and
    included large and small centers in urban and rural locations. The
    results of the sample showed that Job Corps instructor salaries
    averaged $19.89 per hour ($41,371 annually) contrasted with a Bureau of
    Labor Statistics (BLS) national instructor average of $34.62 per hour
    ($71,999 annually). Individual analysis by center indicated some
    variations based on geographical location.
        As part of the 2011 budget, DOL proposes adjusting compensation
    levels to place our instructors on equal footing with their
    counterparts in the public school system. Over the past several years,
    the program has had difficulty in attracting and retaining qualified
    instructors, due to the disparity in income of these two groups.
        Misclassification of employees as independent contractors is a
    significant issue that denies employees benefits to which they are
    entitled and results in revenue losses for the Unemployment Insurance
    Trust Fund and other accounts.
        Question. Please describe how ETA will structure each of the grant
    competitions for the $10,950,000 in State Unemployment Insurance and
    Employment Service Operations (SUIESO) funds requested for the
    misclassification initiative.
        Answer. ETA is currently working to develop an implementation plan
    for these grants. We anticipate the grants that will enable States to
    build their capacity to identify worker misclassification in the
    context of the Unemployment Insurance (UI) program will focus in two
    key areas: technology infrastructure to engage in cross-agency
    information sharing and capacity to do more targeted employer audits.
    These grants will be awarded competitively. State workforce agencies
    responsible for administering the UI program will be the eligible
    grantees.
        The second type of grant will focus on States that have been
    aggressive and innovative in developing processes to identify and
    correct worker misclassification in the context of the UI program.
    These grants will be competitive and will require States to have
    demonstrated results as a criterion for receiving an award. States will
    also be required to identify how they will use the grant funds to
    further their ability to be successful in identifying worker
    misclassification.
        Question. Would DOL's misclassification initiative be assisted by
    changes in the Fair Labor Standards Act (FLSA) expanding employer
    record keeping, requiring notices to newly hired workers explaining
    their classification and their rights, increasing penalties against
    employers who misclassify their workers, and protecting workers from
    retaliation for challenging their employment status?
        Answer. Cross-agency collaboration has already begun, under the
    leadership of the Vice President's office, to improve identification of
    worker misclassification across programs. DOL is exploring all possible
    options for addressing misclassification, including ways to provide
    better guidance to both workers and employers, and to increase
    information sharing between DOL agencies and the States that are also
    working on this issue. DOL's Wage and Hour Division (WHD), which is
    responsible for enforcement of the FLSA, is planning to update the FLSA
    recordkeeping regulations. As part of this rulemaking, WHD is
    considering requiring employers to notify workers of their rights under
    the FLSA and their status under FLSA as an employee or independent
    contractor. Your suggestion will be provided to the working group which
    is exploring ways to reduce worker misclassification.

                                     SUIESO

        Question. The 2011 budget request includes $18.52 million for
    administration of the Work Opportunity Tax Credit (WOTC). It also
    indicates that application backlogs may exceed 1 million by the end of
    fiscal year 2011. The congressional budget justification indicates that
    ``ETA proposes to conduct an intensive strategic management analysis to
    identify the administrative tools, process improvements, and IT
    investments that could support States in their efforts to reduce
    pending applications.''
        ETA already has undertaken a ``comprehensive program review'' of
    the WOTC program. What were the findings of this review, and related
    planned and implemented actions? What is the timeline for completing
    the intensive strategic management analysis?
        Answer. In the 2009 comprehensive review of WOTC, ETA used State
    performance reports and information from State and regional WOTC
    coordinators to identify the States that had the largest backlogs. ETA
    then followed up with individual calls to the 10 States with the
    largest backlogs to discuss the reasons for the backlogs and to ask
    them to develop corrective action plans when necessary. Additionally,
    as part of its comprehensive technical assistance strategy, ETA has
    worked with all States to identify the causes of backlogs and
    successful ways to remediate backlogs based on anecdotal information.
    This information is disseminated to States through ETA's regional
    offices. The information obtained from the 2009 review did not yield
    adequate promising practices that could be implemented to reduce
    backlogs, and ETA now believes a comprehensive strategic management
    analysis of the WOTC certification process is necessary.
        This comprehensive strategic management analysis will be used to
    assess application processing system protocols, recommend action to
    improve processing and reduce the current backlog of WOTC applications,
    and recommend information technology (IT) solutions, especially for
    States with little or no automation. The analysis will be based on a
    selected sample of State Workforce Agencies (SWA), and will employ
    various data collection methods such as review of operational material,
    and site visits. Based upon the findings, a report will include
    recommended actions for ETA to provide SWAs with promising tools and
    practices to reduce application backlogs, to improve the application
    process, and to suggest IT solutions reduce application backlogs. Once
    a contract is awarded, ETA anticipates the review to be conducted over
    3 to 4 months, with expected completion by the end of August 2010
        In an era when a growing majority of families are headed by two
    working parents or a single wage-earner, paid leave programs are one
    cornerstone of a vital support system for working families that also
    includes paid sick days for short-term illnesses, increasing the
    availability of flexible work arrangements, and other family-friendly
    initiatives.
        Question. How would funds requested for the new State paid leave
    fund be allocated to States and for what purposes may the funds be
    used?
        Answer. DOL is currently developing a more detailed implementation
    plan for the State paid leave funds requested in the fiscal year 2011
    budget. While DOL anticipates that the bulk of the funds will be given
    to States for implementation grants, because States are in varying
    degrees of readiness for implementation, the Department may offer
    smaller planning or expansion grants. Implementation grants will be
    targeted to those States demonstrating a readiness to implement a State
    paid leave program, and funds may be used for the administrative costs
    associated with ramping up the program such as putting technology
    infrastructure in place and implementing an outreach effort to educate
    workers on their eligibility for benefits. All States will be eligible
    to apply for these grants.
        Question. What further steps does DOL plan to take to promote
    policies that help workers balance their work and family obligations,
    under ETA, the Women's Bureau (WB), and other DOL agencies?
        Answer. In fiscal year 2011 the WB will build on the lessons
    learned from its successful flex-options project. Workplace flexibility
    solutions, such as flexible work schedules, family-friendly leave
    policies, and telework, help employees navigate their work, family, and
    personal responsibilities, while simultaneously helping employers meet
    their recruitment/retention needs and helping communities ease traffic
    congestion 1and reduce their carbon footprints. Utilizing proposed
    funding provided in the fiscal year 2011 submission, WB will work with
    BLS to initiate the collection of data on parental leave, child care
    responsibilities, family leave insurance programs usage, and other data
    related to the intersection of work and family responsibilities. WB
    will work with other DOL and Federal agencies, employers, women's
    organizations, and other stakeholders to use data and expand flexible
    workplace practices, and to promote laws and policies to help workers
    achieve work-life balance.
        Question. What legislative changes are necessary to assist the
    administration in achieving its goals?
        Answer. Apart from the Department of Labor's fiscal year 2011
    Appropriations Act, no additional Federal legislation is necessary to
    implement the State paid leave grants. Should the need for legislative
    changes be identified in our ongoing work in this area, we will be
    happy to work with the Congress to develop legislative proposals.

                        INJURY AND ILLNESS RECORDKEEPING

        Question. This subcommittee has raised concerns over the past
    several years about the underreporting of workplace injuries and
    illnesses, and directed OSHA to enhance its oversight and enforcement
    of employer injury and illnesses recordkeeping. As a result, OSHA has
    initiated a national emphasis program (NEP) designed to address this
    issue.
        Why did OSHA complete almost one-third fewer recordkeeping
    inspections than targeted for fiscal year 2009? How will OSHA ensure
    that NEP recordkeeping inspections stay on track in 2010? What has OSHA
    found through its NEP, particularly its programmed inspections in
    fiscal year 2009 and fiscal year 2010? How does the 2011 budget request
    build on these findings? How much funding is included in the request to
    continue the program?
        Answer. OSHA's NEP on recordkeeping was originally scheduled to be
    implemented on August 1, 2009. After undergoing extensive revisions
    during summer 2009 to ensure that the NEP would lead to the detection
    of the underreporting of injuries and illnesses, the NEP was
    implemented on September 30, 2009. Due to the extensive work on
    preparing the content and administration of the NEP, the recordkeeping
    inspection total for fiscal year 2009 dropped, and was not part of the
    NEP.
        The recordkeeping NEP is designed to be maximally sensitive to
    under-recorded and mis-recorded injuries and illnesses in selected
    establishments, and to enforce the agency's recordkeeping requirements.
    Inspections under the NEP assess the accuracy of the information
    employers are required to record on the OSHA 300 log. The agency issues
    citations and penalties, as appropriate, for recordkeeping violations.
    The NEP targets establishments operating in historically high-rate
    industries that have reported low rates of injuries and illnesses. The
    program also includes establishments in the construction and poultry-
    processing industries, due to the inherently high-hazard nature of the
    work in those industries, and to questions that have been raised
    regarding recording practices in those industries.
        Assessments of the accuracy of establishment-specific recordkeeping
    data are made by conducting interviews with employers, employees,
    company recordkeepers, first-aid providers, and healthcare providers.
    The assessments include a review of relevant records and documentation,
    such as medical records, workers' compensation records, and first-aid
    records. The NEP complements other efforts to evaluate and verify the
    accuracy of injury and illness rates, including OSHA's data initiative
    audit, and the BLS' efforts.
        In fiscal year 2010, OSHA intensified training of its Compliance
    Safety and Health Officers (CSHOs) on identifying potential problems in
    recordkeeping data and systems. The agency's Training Institute staff
    revised the core curriculum for CSHOs to include a week-long mandatory
    training course on recordkeeping. OSHA plans to continue its
    recordkeeping NEP through fiscal year 2010, at which time the program
    will be assessed and recommendations will be made on whether or not to
    continue it in its present form. Assuming the assessment at the end of
    this fiscal year leads to the recordkeeping NEP continuing in its
    present form, the fiscal year 2011 budget request makes $1 million
    available for the recordkeeping enforcement initiative to maintain the
    number of recordkeeping inspections planned for fiscal year 2010.
        Following are the results of Federal and State inspections
    conducted under the recordkeeping NEP during fiscal year 2010.
    Recordkeeping NEP Inspections as of 4/19/10
        OSHA has initiated 104 Federal inspections under the recordkeeping
    NEP through April 19, 2010. Of the 104 inspections, 11 have involved
    the issuance of citations for 45 violations of the recordkeeping
    regulation (part 1904), resulting in $25,450 of penalties. It should
    also be noted that the vast majority of the 104 inspections are still
    open and subject to the citation of additional violations.
    State Plan Inspections
        Total inspection = 33 (31 are from the State of Oregon)
        NIC inspections = 15

                       HIRING PLAN FOR ENFORCEMENT STAFF

        Question. The budget request includes $227.149 million for Federal
    enforcement, which is an increase of $29.203 million and 160 full-time
    equivalents (FTE) more than the 2009 level.
        What is DOL's plan (timeline and associated activities) for hiring
    these additional staff?
        Answer. OSHA is committed to a hiring plan that emphasizes
    increasing its enforcement staff. Since February 2009, the agency's
    regional offices have hired 185 staff, of whom more than 150 are CSHOs
    and 13 are whistleblower investigators. The agency has a target of
    filling 270 positions during fiscal year 2010, and estimates that 150
    possible hires are currently in the selection process, 100 of which are
    CSHOs. The number of hires since February 2009 and the target for
    hiring in fiscal year 2010 both account for historical attrition rates,
    therefore leading to goals that are greater than the requested FTE
    increases in fiscal year 2010 and fiscal year 2011.
        OSHA maintains relationships with a wide variety of academic
    institutions and professional and trade groups to promote career
    opportunities within the agency. A Federal Career Intern Program has
    been implemented to add another facet to the agency's recruitment
    strategies for attracting highly qualified CSHOs, including future
    whistleblower investigators, to help the agency meet its hiring goals.

                             ERGONOMICS ENFORCEMENT

        Question. Last year, the subcommittee encouraged OSHA to consider
    collecting information on musculoskeletal disorders in a separate
    column on the agency's recordkeeping form. OSHA plans to issue a final
    rule that will allow for the collection of this information.
        How will this request enable OSHA to move forward on ergonomics-
    related enforcement activities?
        Answer. A final rule will be issued in 2010 to revise the
    Occupational Safety and Health Administration's (OSHA) recordkeeping
    form to restore a separate column on musculoskeletal disorders (MSD)
    that was removed from the form in the last administration. Restoring
    this column will improve the workplace injury and illness data
    collected by OSHA and BLS. Having more complete and accurate data will
    further our understanding of work-related MSDs, which is certainly
    beneficial to any ergonomics research, and also better inform employers
    about ergonomic hazards in their workplaces.
        OSHA has also launched a recordkeeping NEP, which will help ensure
    that musculoskeletal injuries are being recorded accurately by
    employers filling out the OSHA recordkeeping logs.
        OSHA plans to continue to use the general duty clause, when
    appropriate, for enforcement when inspections find unaddressed hazards
    causing or likely to cause musculoskeletal injuries.

                           EVALUATIONS OF STATE PLANS

        Question. The subcommittee provided additional funding under the
    OSHA State Plan program to help State Plan States rebuild capacity that
    has been lost in recent years. OSHA has also announced plans to conduct
    baseline special evaluations of each State plan during fiscal year
    2010. These evaluations seek to better assess the current performance
    of each State plan and identify issues of concern.
        What is the timeline for assessing these plans? How will OSHA help
    State Plans address deficiencies identified during these evaluations?
    How will the 2011 budget request help meet the requirement that State
    plans be at least as effective as Federal programs?
        Answer. Since December 2009, OSHA regional offices have been
    conducting enhanced evaluations of State plan performance during fiscal
    year 2009. These reviews, which emphasize enforcement, are in the
    process of being completed, and we plan to issue the special baseline
    evaluation reports by early this summer. Upon completion of the
    reports, the States will be expected to develop corrective action plans
    with timetables to address any deficiencies identified. We do not
    expect to find significant deficiencies in all State plans, but will
    continue to address problems that we do find and ensure that the State
    plans fulfill their commitments for effective programs. OSHA offers
    formal training to State plans and will provide informal training and
    technical assistance at the regional level upon request in areas such
    as accident investigations and enforcement of specific standards. In
    addition, OSHA will continue to communicate with States and monitor
    their progress in meeting their commitments as part of the national
    OSHA program.
        The additional $1.5 million in grant funding requested for the
    States in fiscal year 2011 is intended to provide additional funding
    for increased personnel, staff training and equipment, and specific
    enforcement initiatives, which should enable the State programs to
    better keep pace with Federal developments and remain at least as
    effective as the Federal program. This funding should also allow all
    States to fill vacant positions and prevent them from reducing their
    programs due to budget shortfalls. As the economy improves, States are
    expected to use the additional funds for program enhancements.

                           TIMELINES FOR RULEMAKINGS

        Question. Please identify the timelines for completion of the
    safety and health standards work with respect to notices of proposed
    rulemaking (four expected in each of fiscal years 2010 and 2011) and
    final rules (five expected in fiscal year 2010 and four expected in
    fiscal year 2011).
        Answer. OSHA is revising its regulatory agenda to reflect the
    administration's priorities and new initiatives. The regulatory program
    is being expanded with the additional personnel authorized in the
    fiscal year 2010 budget, and the expansion will continue if the
    additional resources requested in fiscal year 2011 are provided. Five
    proposed rules are planned during fiscal year 2010. On January 29,
    2010, OSHA published a proposal for a musculoskeletal column on the
    OSHA 300 injury and illness log, and received comments until March 30,
    2010. The agency is reviewing the comments, and anticipates publishing
    a final rule in July 2010. Additionally, a proposal for walking and
    working surfaces will be published this spring. Proposals for standards
    improvement and consultation agreements are in the final stages of
    review, and will also be published soon. Finally, a proposal and direct
    final rule to implement a court remand for the hexavalent chromium rule
    were published on March 16, 2010, and the direct final rule is
    anticipated to become effective during fiscal year 2010.
        In addition to the hexavalent chromium and musculoskeletal
    disorders column rulemakings, OSHA is on target to publish five other
    final rules during fiscal year 2010. Three of these, including two
    whistleblower standards and the final rule for construction cranes and
    derricks, are considered to be high-priority rulemakings. The cranes
    and derricks rule was submitted to the Office of Management and Budget
    (OMB) for Executive Order review on April 7. The other two rules are
    currently in internal review, pending submission to OMB. OSHA has also
    completed final actions for the abbreviated Portacount respirator fit-
    testing method rulemaking and the acetylene consensus standards update.
        OSHA projects that the agency will publish four proposals in fiscal
    year 2011. Two new, high-priority items were added to the spring
    regulatory agenda, a rulemaking on injury and illness prevention
    programs and one to modernize OSHA's injury and illness recordkeeping
    regulations. The next step for the injury and illness prevention
    programs rulemaking is to hold stakeholder meetings in anticipation of
    publishing a proposal during fiscal year 2011. Additionally, during
    fiscal year 2011, the agency plans to publish proposed rules for
    beryllium, silica, and an update of the injury and illness
    recordkeeping industry exemptions to be consistent with newer industry
    classification systems.
        OSHA plans to publish five final rules during fiscal year 2011. The
    final rules for nationally recognized testing laboratories,
    consultation agreements, and shipyard general working conditions are
    anticipated to be completed at the beginning of fiscal year 2011. The
    final rule for electric power and generation is also on track for
    publication in fiscal year 2011. Finally, the hearings to update the
    hazard communication rule have been completed, and the posthearing
    comment period will close on May 31, 2010. After OSHA reviews the
    comments received, the agency will begin work on the final rule--
    preamble, regulatory text, and economic analyses--which is projected to
    be published in fiscal year 2011.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye

              SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP)

        Question. In 2010, funds appropriated for the SCSEP were increased
    to provide more opportunities in paid community service training and
    service for unemployed, low-income older persons.
        What plans do you have for future support of this dramatic increase
    in funding for a program of considerable importance to low-income
    seniors and community service agencies throughout the country?
        Answer. The fiscal year 2011 budget requests a total of
    $600,425,000 for the SCSEP. This amount equals the base amount of the
    fiscal year 2010 appropriation and is a $28.5 million increase more
    than fiscal year 2009. The fiscal year 2010 appropriation of
    $825,425,000 included a one-time special infusion of $225 million into
    SCSEP to quickly serve additional unemployed, low-income seniors in the
    current difficult economic times. However, as the economy continues to
    improve, we believe that the fiscal year 2011 budget request of
    $600,425,000 is appropriate and will provide part-time employment
    opportunities in community service for low-income older workers.
        In part, due to the recession, many seniors have expressed a need
    for skill training funds specifically appropriated for low income older
    workers in the Workforce Investment Act (WIA) funded one-stop centers.
        Question. How is the Department of Labor (DOL) planning to address
    the needs of a growing older population of job seekers in the workforce
    development system in the near to intermediate term?
        Answer. Older workers will account for an increasingly large
    portion of America's workforce in the decades ahead. The public
    workforce system under the WIA has served an increasing number of older
    workers over the past few years and currently provides job training and
    employment services to older workers at a rate roughly equal to their
    share of the total unemployed workforce.
        DOL plans to address the needs of this growing older population of
    job seekers in several ways. We will continue to help employers
    recognize the value of older workers as talented and productive
    employees and as mentors to younger workers. Last summer, we invested
    $10 million in 10 demonstration grants under the Aging Worker
    Initiative (AWI). These grants are designed to expand the public
    workforce investment system's understanding of how to best serve older
    workers, and develop models to share with all local workforce
    investment areas. AWI focuses on providing training and related
    services to individuals 55 and older that result in employment and
    advancement opportunities in high-growth sectors. Its ultimate goal is
    to provide better, more expansive services to older Americans for many
    years to come. In fiscal year 2011, DOL will utilize the results of the
    AWI demonstration grants to build the capacity of the public workforce
    system to better serve additional older workers who need and want good
    jobs. DOL will build on lessons learned and its experience under the
    ``regular'' SCSEP and additional American Recovery and Reinvestment Act
    (ARRA) investments to encourage and expand ``green'' jobs opportunities
    for older, low-income workers. In addition, DOL will continue to
    encourage the One-Stop Career Center system to increase its role in
    assisting older workers who want to update their skills, helping job-
    ready older workers obtain employment, and breaking down the barriers
    to fair and diverse work places for older workers.
        The national sponsor for the SCSEP serving American Indians often
    operates in areas with unemployment rates considerably higher than the
    average for the United States. This makes placement into unsubsidized
    employment extremely difficult and reflects poorly on the sponsor's
    evaluation.
        Question. Does DOL have plans for recognizing local unemployment
    conditions when evaluating placement rates for national sponsors
    serving seniors in such areas?
        Answer. DOL currently takes into account local economic conditions
    during the annual performance goal negotiation process with each
    grantee, including two grantees that serve primarily the American
    Indian community--the National Indian Council on Aging and the
    Institute for Indian Development. The past performance of each SCSEP
    grantee (which reflects conditions faced at the local level) is also a
    key factor in determining performance goals. During the annual
    negotiation process with DOL, each grantee is urged to present
    information about unemployment and other economic factors which create
    additional barriers to meeting performance goals. In addition, any
    grantee may present new information during the program year regarding
    local or regional economic or environmental emergencies that could
    justify an adjustment of goals. Mid-year goal adjustments can also be
    made based on national economic conditions.
        The national sponsor serving Asian and Pacific Island aging
    communities through SCSEP has articulated high barriers to providing
    service: 85-95 percent of enrollees have limited or non-English
    speaking proficiency (depending on the project site), some have
    literacy issues, and many are new immigrants with limited U.S. work
    history and access to social security or pensions. In short, this
    sponsor reaches out to the most difficult to serve and vulnerable of
    our seniors. These characteristics make it unrealistic to continuously
    meet performance requirements. A distinct challenge, for example, is
    the average earnings performance measure which requires that enrollee
    who exit the program for unsubsidized employment earn an average
    $13,000 per year. The sponsor considers it a success when enrollees
    move on to unsubsidized employment, particularly with benefits.
    However, evaluating program performance based on earnings level
    penalizes an otherwise successful performance.
        Question. What is DOL doing to address these special situations
    with SCSEP so as to minimize the negative aspects of a ``one size fits
    all'' approach to performance evaluation?
        Answer. DOL does not use a ``one size fits all'' approach to
    performance evaluation; rather it takes into account labor market and
    economic conditions. For example, the National Asian Pacific Center on
    Aging (NAPCA) serves a large number of participants with language
    barriers--89 percent in the four quarters ending December 31, 2009--and
    its overall performance is good. While NAPCA has not yet met its
    negotiated entered employment rate goal of 39.9 percent for the 6-month
    period between July 1 and December 31, 2009, it has exceeded its
    average earnings goal of $6,490 for SCSEP participants placed in
    unsubsidized full- or part-time employment. In addition, its employment
    retention goal for participants who obtained employment is only 0.1
    percent below the performance goal of 67.6 percent for that time
    period.
        The Employment and Training Administration (ETA) is currently in
    the process of implementing a regression-based model for the major
    programs in the workforce system. This regression-based model addresses
    the negative aspects of a ``one size fits all'' approach to performance
    management because it applies economic conditions, such as the
    unemployment rate, and program participant characteristics to adjust
    program goals and targets. ETA is currently applying this model to the
    SCSEP national performance goals and plans to extend the model to State
    and local areas over the next 2 years.
        National sponsors of the SCSEP serving American Indians and Asian
    Pacific Islander Americans are often limited to serving only those
    enrollees in the counties assigned by DOL. This leaves large segments
    of the American Indian and Asian Pacific Islander American seniors
    inaccessible to these national sponsors best-equipped to serve these
    elders in terms of language and cultural sensitivities.
        Question. What can DOL do to better align these national sponsors
    with the seniors they are equipped to and charged with serving?
        Answer. Current legislation directs DOL to allocate authorized
    positions on a county level. Because the American Indian and Asian
    Pacific Islander populations are widely dispersed, DOL requires each
    SCSEP grantee to serve the minority individuals residing in the
    county(s) where they provide service. Nationally, SCSEP serves a
    substantially higher proportion of minorities than their incidence in
    the population. For example, 48.9 percent of SCSEP participants are
    minority compared with 36.8 percent in the U.S. population. SCSEP also
    serves slightly higher proportions of three specific minority groups--
    Blacks, American Indians, and Pacific Islanders--than their incidence
    in the population. The following table shows the distribution of
    minority participants served by the SCSEP grantees as a whole and by
    each of the three current minority grantees during calendar year 2009.

    ----------------------------------------------------------------------------------------------------------------
                                                       Number served   Number served   Number served
                                       Total number       by the          by the          by the         Total for
       SCSEP minority participants     served by all  National Asian     National      Institute for     minority
                                      SCSEP grantees  Pacific Center  Indian Council      Indian         grantees
                                                         on Aging        on Aging       Development
    ----------------------------------------------------------------------------------------------------------------
    Hispanic, Latino, or Spanish ori-          9,660              21              57               1              79
       gin..........................
    American Indian or Alaska Native           2,160               1             438              24             463
    Asian...........................           2,696             736               7  ..............             743
    Black or African American.......          27,135              44              71              98             213
    Native Hawaiian or Pacific                   598              13               1  ..............              14
     Island-  er....................
    ----------------------------------------------------------------------------------------------------------------

        We are working to complete a report on service to minorities and
    will have more recent data in a few weeks. In the interim, the
    following table demonstrates the percentage of minority groups served
    by the SCSEP in comparison to the percentage of minority groups in the
    U.S. population aged 55 and older as of 2006. Data from the past 2
    years show no disparities in service that impact minorities overall and
    few for individual minority groups.

        As the economy slows, global competition intensifies, and energy
    costs rise, many industries such as agriculture are releasing workers.
    Nowhere is this more evident than in Hawaii with the termination of all
    dairy operations on the island of Oahu and the rapid collapse of
    century-old sugarcane and pineapple plantations throughout the State.
    These dramatic changes are occurring at a time of increased awareness
    of Hawaii's fragile food security and increased need for food safety at
    all levels of the food production chain.
        Question. What steps are you taking to harness the potential of
    dislocated agricultural workers to address the unique food security and
    food safety issues found in Hawaii?
        Answer. The WIA of 1998 established a decentralized public
    workforce system where information about and access to a wide array of
    job training and employment services are available through local One-
    Stop Career Centers. DOL allocates WIA funds to States using statutory
    formulas, and States such as Hawaii, in turn, use similar formulas to
    allocate funds to local workforce areas to be administered by local
    workforce investment boards that plan and oversee the local system.
        Workers that lose their jobs can access three levels of service
    through local One-Stop Career Centers: (a) ``core'' services including
    outreach, job search and placement assistance, and labor market
    information; (b) ``intensive'' services including comprehensive
    assessments, development of individual employment plans, career
    planning and counseling, and supportive services such as child care and
    transportation; and (c) ``training'' services, including occupational
    classroom or on the job training that can be combined with basic skills
    training, and entrepreneurial training. Eligible farmworkers in Hawaii
    also can access a range of services through the National Farmworker
    Jobs Program grantee Maui Economic Opportunity, Inc. located in
    Wailuku. Thus, Hawaii is well-positioned to address the needs of the
    local economy and to help workers affected by the termination of food
    production operations transition to good jobs. As the State of Hawaii
    develops policies and strategies to address food security and food
    safety issues, the public workforce system will be available to support
    its workforce development needs.
        Question. Can you share your DOL's vision of what a robust, highly
    effective summer jobs program looks like, how we get there, and how we
    make it as inclusive and responsive to the needs of all eligible youth?
        Answer. A robust, highly effective summer jobs program would
    include a broad outreach and recruitment strategy focusing on both in-
    school youth and disconnected, out-of-school youth; broad employer
    outreach in both the public and private sector to ensure a broad range
    of summer job options for youth including opportunities in high-growth
    or high-demand industries such as healthcare and green jobs; and, an
    assessment of each youth's skill level, interests, and needs in order
    to match them to the summer job that would provide the, greatest
    benefit for them and their employers. In addition, such a summer jobs
    program would offer a thorough orientation for both youth and
    employers; work readiness training for youth to prepare them for their
    summer job; a monitoring strategy for both youth and worksites to
    ensure quality work experiences and to provide support to both youth
    and employers if any issues with the youth's employment arise; and
    transition services following summer employment to ensure youth
    successfully transition into education or to unsubsidized employment.
    Through the implementation of summer employment opportunities under
    ARRA, local programs are on their way to achieving this vision, and
    through DOL's fiscal year 2011 budget request for a Youth Innovation
    Fund, DOL will fund innovative summer employment models to continue
    these efforts and learn which particular approaches produce the best
    employment and educational outcomes for youth. The strategies
    identified above will assist in making summer employment programs
    inclusive, responsive to the needs of all eligible youth, and benefit
    local communities.

                                APPRENTICESHIPS

        Question. Madam Secretary, I believe we have an underappreciated
    and underutilized jewel in our Nation's apprenticeship system. As you
    know, exceptional apprenticeship programs combine rigorous academic and
    technical instruction with authentic, on-the-job training and learning.
    As a result, these programs are highly valued by employers, unions, and
    students.
        How we can continue to grow our apprenticeship programs, and
    rebuild our Nation's ability to fill middle and high-skills occupations
    and grow key industries, such as those in the emerging green economy?
        Answer. ETA continues to focus on expanding registered
    apprenticeship opportunities for America's workers, enabling them to
    ``learn while earning'' along career paths to middle- and high-skilled
    occupations, particularly those in high-growth industries and the
    emerging green economy. DOL's efforts have centered on: (a) expanding
    resources available to the National Apprenticeship System; (b)
    increasing the budget for the Office of Apprenticeship to plan,
    encourage, and register apprenticeship programs; and (c) promoting
    partnerships between the broader workforce system and registered
    apprenticeship programs.
        For example, a significant number of DOL's recently awarded ARRA
    competitive grants included registered apprenticeship as a critical
    partner in training and employing thousands of workers in green
    industries and occupations. In addition, DOL recently awarded $6.5
    million in grant funds to 11 national organizations to expand and
    advance apprenticeship programs, with many upgrading their training
    efforts to meet the needs of the emerging green economy. Finally, DOL's
    fiscal year 2011 budget request includes a proposal for an employer-
    paid fee on H-2B visas that would support a new grant initiative to
    expand registered apprenticeship at the national, State, and local
    levels.
        DOL's fiscal year 2011 budget would increase the budget for the
    Office of Apprenticeship by approximately 35 percent from the fiscal
    year 2009 budget of about $21 million. This increase will ensure that
    the Office of Apprenticeship will meet its core responsibilities for
    the promotion of registered apprenticeship, partnering with State
    agencies, protecting the welfare of America's apprentices, ensuring
    equal opportunity, and fulfilling new responsibilities resulting from
    recent regulations that strengthen performance accountability for the
    National Apprenticeship System.
        DOL also encourages State and local workforce agencies and boards
    to expand registered apprenticeship programs that can prepare workers
    for careers in the renewable energy sectors and for other ``green
    jobs''. We have developed, offered, and plan to expand a series of
    regional ``Collaborate for Success: Partnering with Registered
    Apprenticeship Action Clinics'' where State-based teams learn how to
    incorporate registered apprenticeship into their workforce development
    strategies and learn how to improve partnerships with community
    colleges, community-based organizations, healthcare providers,
    ``green'' employers, and economic development entities.
                                     ______

                  Questions Submitted by Senator Patty Murray

                                 STATE PROGRAMS

        Question. Along with 26 other States, my home State of Washington,
    under an agreement with Occupational Safety and Health Administration
    (OSHA), operates an occupational safety and health program in
    accordance with section 18 of the Occupational Safety and Health Act of
    1970. Washington State's OSHA plan is administered by the Washington
    State Department of Labor and Industries. The departments' primary
    focus is on protecting the safety and welfare of Washington's 3 million
    plus workers with on-the-job safety and health through inspections and
    enforcement programs through voluntary consultations and training. They
    also help protect consumers from unsound building practices, combat
    illegal employment practices, and help develop the State's skilled
    workforce through apprenticeship programs. In years past the successes
    of our State programs has been jeopardized by the lack of funding from
    the Federal level to maintain current programs let alone to expand and
    implement new safety standards for new equipment and or technologies.
        Does the Department of Labor (DOL) have any ideas on how the State
    and Federal level can worker closer together to further implement
    workplace safety standards?
        Answer. OSHA and the States that operate approved State plans,
    including Washington State, maintain an ongoing partnership to ensure
    protection for all the Nation's workers. OSHA meets three times a year
    with the full membership of the Occupational Safety and Health State
    Plan Association (OSHSPA), which represents all 27 States operating
    State plans, and an additional three times a year with the OSHSPA Board
    of Directors. At these meetings, the attendees discuss Federal and
    State initiatives, and share information to enhance both Federal and
    State programs. OSHA's Regional Administrators and their staffs work
    with the State plans on a daily basis to coordinate efforts, provide
    technical assistance, and monitor their performance. State plan
    representatives serve on task forces with OSHA to address issues such
    as newly identified hazards and compliance initiatives. While States
    may focus their enforcement and outreach activities on State-specific
    industries and hazards, States also participate in OSHA National
    Emphasis Programs to address selected hazards on a nationwide basis.
        OSHA is also working with the States to broaden their participation
    in more of these national programs in the interest of greater
    nationwide consistency. The State plans all participate in OSHA's
    management information system; information on State inspections is
    available on OSHA's Web site and in its database in exactly the same
    manner and detail as OSHA's Federal inspections.
        Finally, in an effort to ensure that State plans are at least as
    effective as the Federal plan, we are currently conducting special
    reviews of all of the State plans, which will include recommendations
    on improvements they can make in their operations.
        Question. Can I have a commitment from you that we will continue to
    keep State OSHA plans fully funded and functional so as not to increase
    the heavy burden of inspections and cases handled on the Federal level?
        Answer. OSHA's State plan funding levels are set by Congress as
    part of the agency's annual appropriation, and OSHA will continue to
    distribute all available funds appropriated by Congress in accordance
    with the Act. No State plan is required by law to contribute more than
    a 50 percent match of the available Federal funds for the total costs
    to the State of their safety and health program. However, many States
    have chosen to contribute significant additional funding. Currently, 19
    of the 27 approved State plans, including Washington, contribute
    additional State funds over and above the amount that OSHA allocates to
    them from amounts made available for State plans in the agency's annual
    appropriation. The other eight States provide the 50 percent share, the
    same as the Federal funds made available to them.
        The fiscal year 2010 appropriation included an $11.8 million
    increase for State plans, the first significant funding increase in
    many years. The funds were distributed to States in accordance with a
    funding formula that takes into account a State's worker population and
    the extent to which its industries are hazardous. The eight States
    which were unable to match all or part of the increase for this fiscal
    year will be given until fiscal year 2012 to obtain matching funds. The
    fiscal year 2011 budget requests $105.9 million for State plan
    programs, an increase of $1.5 million from the fiscal year 2010 level.

                                  REGULATIONS

        Question. On OSHA's rule on cranes and derricks--this rule to
    protect construction workers has been in the works for years and
    repeatedly delayed. The latest regulatory agenda says the final rule
    will be issued in July 2010.
        Is this rule on track to be issued by this date?
        Answer. Yes. The final rule for cranes and derricks has been
    submitted to the Office and Management and Budget in anticipation of a
    July 2010 publication date.
        After a number of years of inaction under the last administration,
    we appreciate that OSHA is now moving forward to develop and issue
    needed regulations. There are many serious hazards that need to be
    addressed. I would like to ask you about a few specific rules and when
    we might expect movement.
        Question. OSHA's rule on silica has also been repeatedly delayed.
    Will a proposed silica rule be issued in July as listed in the
    regulation agenda?
        Answer. Newly appointed Assistant Secretary David Michaels is
    providing strong leadership and is committed to moving forward with the
    silica rulemaking. OSHA recently completed a peer review of the health
    effects and risk assessment sections needed to develop the proposed
    rule. The agency is continuing to refine the scientific risk assessment
    and develop the robust economic analysis required to support a proposed
    rule; consequently, the proposal will not be issued in July as had been
    projected in last fall's regulatory agenda. Please be assured that the
    rulemaking for silica remains a high priority for the agency. OSHA is
    working to complete these analyses and the proposed rule is scheduled
    to be published in February 2011.
        Question. In 2007, 14 workers were killed at the Imperial sugar
    refinery in Georgia when sugar dust caused a deadly explosion. The
    Chemical Safety Board recommended that OSHA needs a regulation to
    prevent these kinds of explosions in the future.
        What are OSHA's plans for issuing a proposed rule and a final rule
    on combustible dust?
        Answer. On October 19, 2009, OSHA published an Advanced Notice of
    Proposed Rulemaking (ANPR) for combustible dust. The comment period
    officially closed in January 2010. More than 110 comments have been
    submitted, which are currently under review by OSHA personnel. On
    December 14, 2009, OSHA hosted two stakeholder meetings in Washington,
    DC. Two additional meetings were held in Atlanta, Georgia, on February
    17, 2010. Nearly 100 stakeholders have expressed their views to OSHA so
    far. Two more meetings are scheduled for Chicago on April 21, 2010.
        OSHA's economists are analyzing the responses to the ANPR and
    reviewing other sources of information to help analyze the economic
    impacts of a proposed rule. A Small Business Regulatory Fairness Act
    Panel is being planned for the spring of 2011 to solicit input on the
    potential economic impacts on small businesses. OSHA is drafting a
    proposed rule as it continues to conduct research, solicit and analyze
    input from stakeholders, and review responses to the ANPR. OSHA
    anticipates that a proposed rule for combustible dust will be published
    in 2012.

                               MISCLASSIFICATION

        Question. As you know, we've been advocating, and the subcommittee
    has been focused on the problem of employee misclassification as
    independent contractors for some time now. Those efforts have resulted
    in the President's active support new budget proposals and a new joint
    Labor-Treasury initiative to ``strengthen and coordinate Federal and
    State efforts to enforce statutory prohibitions, identify, and deter
    misclassification of employees.'' The budget includes $25 million to
    support four program components.
        Misclassification not only deprives workers of numerous rights and
    benefits (e.g., overtime pay, the employer's share of Social Security
    and Medicare contributions, rights to a safe workplace, civil rights
    protections, etc.), but it also gives tax cheats an unfair advantage in
    competing for business over responsible employers who follow the law.
    And, at a time of significant budget deficits, it is a major source of
    revenue losses for the Federal and State governments.
        I was excited to see that this administration is being proactive
    about the problem of misclassification abuses.
        How soon will you be able to get this initiative up and running?
        Answer. Should the Congress provide the requested funds, the
    different elements that are a part of the initiative will be
    implemented at various points over the next year. The DOL's budget
    request for fiscal year 2011 includes $25 million for DOL, including
    $12 million for increased enforcement of wage and overtime laws in
    cases where employees have been misclassified; these funds will allow
    us to hire more investigators and provide better training on how to
    determine who is an employee and who is an independent contractor. Even
    though these funds will not be available until fiscal year 2011, we are
    already planning how best to target enforcement to identify and remedy
    widespread misclassification and we are emphasizing this issue in our
    current, fiscal year 2010 enforcement strategy.
        Question. The proposal indicates this is a ``joint Treasury-Labor
    initiative'' to detect and deter misclassification.
        What exactly will be the Department of the Treasury's role in this
    joint effort?
        Answer. DOL has established a working group, headed by the Wage and
    Hour Division (WHD) Deputy Administrator, which includes members from a
    number of DOL agencies, including OSHA and ETA. This working group is
    also working with the Vice President's Middle Class Task Force and the
    Department of the Treasury on a Government-wide effort to develop
    strategies to address misclassification.
        The Department of the Treasury is seeking legislation to allow it
    to better define and clarify worker classification standards--which
    benefits workers and firms by reducing uncertainty--and to
    prospectively reclassify misclassified workers. The President's budget
    estimates that this would increase Treasury receipts by more than $7
    billion over 10 years, much of it consisting of unpaid taxes.
        Question. I am glad to see that the portion of the initiative that
    will be implemented by the WHD is appropriately targeted to industries
    and employers that have been identified as having a record of
    significant misclassification violations.
        Can you elaborate on other aspects of the initiative that are
    designed to maximize your investigative resources, for instance
    coordination with State efforts?
        Answer. The DOL's working group is exploring ways for all DOL
    agencies to provide better guidance to both workers and employers and
    increase information sharing between DOL agencies. Over the next few
    months, the working group plans to bring in a diverse array of
    stakeholders, including unions, worker advocates, and employer groups,
    to get their input on misclassification and what steps we should take.
    We are also planning to meet with representatives from State
    misclassification task forces to learn from their experiences.
      --I think it is especially important that you have proposed a pilot
            program of competitive grants to reward and help States that
            have stepped up efforts to detect and prosecute
            misclassification violations. These programs, usually
            undertaken by State Unemployment Insurance Administrators, are
            severely understaffed and underfunded.
        Question. What does the DOL hope to achieve with the grants
    program?
        Answer. An additional $10,950,000 is requested for the ETA for two
    initiatives focused on increasing the capacity to address
    misclassification within the Federal/State administered Unemployment
    Insurance program. The first initiative provides states the opportunity
    to compete for grants to increase their capacity to participate in data
    sharing activities with the IRS and other Federal and State agencies;
    to implement targeted audit strategies; establish a cross-State agency
    task force to target egregious employer schemes to avoid taxation
    through misclassification, and to develop education and outreach
    programs. The second initiative would pilot a high-performance award
    program designed to encourage States to improve misclassification
    efforts. States that are most successful (or most improved) at
    detecting and prosecuting employers that fail to pay their fair share
    of taxes due to misclassification and other illegal tax schemes will be
    rewarded.

                        BUREAU OF LABOR STATISTICS (BLS)

        Question. Madam Secretary, the President's budget for the BLS
    includes a new initiative designed to restructure the Current
    Employment Statistics (CES) Program. This CES initiative proposes
    reducing funding to the State labor market information (LMI) agencies
    by $12 million (a 50+ percent reduction in BLS funding to the States
    for CES) while re-programming $7 million to fund BLS staff to make
    improvements in data collection and survey response rates. As proposed,
    the net savings to the CES program would be $5 million. BLS indicates
    that this change will have no net impact on data quality and variance
    at the national level. While this savings goal is laudable in this
    period of significant budget concerns, I have some concerns about the
    negative impact that this move could have on State LMI agencies in
    maintaining their capacity to generate, analyze, and disseminate data
    to State and local policymakers--especially when data is so critical to
    guiding people toward employment opportunities during this recovery.
        BLS indicates that this proposal will improve data quality overall
    and provides evidence that the proposed change to the CES program would
    have little impact on national employment estimates. However, a number
    of State LMI agencies have expressed concern that this move will reduce
    BLS' ability to access local knowledge in making estimates (given the
    reduction in State staff). The State LMI agencies also contend that the
    change will increase the variance for employment estimates reported in
    about one-third of the States (according to BLS's technical
    explanation). This greater variance in State or regional estimates will
    be much more difficult to explain to State or local policymakers using
    the data. The LMI agencies are responsible for explaining State
    estimates from this program to budget and tax revenue forecasters,
    economic developers, workforce developers, and other policy makers that
    rely on the CES to inform their decisionmaking. As proposed, this
    change would substantially reduce the State knowledge base in
    supporting user questions about this important program since fewer
    staff will be familiar with how the estimates are being generated and
    the rationale behind some variance.
        Furthermore, there is some concern that this ``centralization''
    could have significant long-term implications for the Federal-State
    statistical system, first established during the Great Depression.
    Certainly, enormous advances in information technology have occurred
    since the program was put into place, providing opportunities for
    increased efficiencies and shifting responsibilities. This may be an
    appropriate time to conduct a thoughtful, thorough review of the
    current state of the Federal-State cooperative effort, not just for the
    Current Employment Statistics program, but also for other BLS data
    programs such as Local Area Unemployment Statistics, Occupational
    Employment Statistics, the Quarterly Census of Employment and Wages,
    and Mass Layoffs Statistics. Such a review would provide the basis for
    implementing a more considered, effective approach to a 21st system
    cooperative system, one that takes full advantage of the complementary
    strengths of BLS and the LMI agencies.
        Question. I'd like to ask DOL to provide a long-term vision for how
    the Federal-State statistical system is to be strengthened, improved
    and expanded. And I'd like to ask the department to consider
    undertaking a deliberative review of this Federal-State cooperative.
        Answer. The DOL thanks the Senator for sharing her concerns about
    the BLS proposal to restructure the CES program. While the proposal
    does reduce the number of State-funded positions, it reduces the
    workload on States commensurately. Moreover, the proposal allows for
    States to retain about 100 positions for collecting and providing BLS
    with local knowledge for making estimates, and for conducting analysis
    and dissemination of the estimates to State and local users.
        Regarding State concerns about the quality of the estimates, BLS
    research comparing State-made to BLS-made estimates indicates that
    about one-third of the former showed smaller errors (when benchmarked
    to the annual comprehensive employment count from the unemployment
    insurance system). However, BLS-made estimates were comparable in
    accuracy for one-third of States, and more accurate for another third
    of States. For this research, BLS made its estimates in a completely
    automated fashion with no analyst review or intervention in the
    estimation process. After the implementation of this proposal,
    estimation will be conducted by a staff of about 30 BLS analysts and
    the quality of BLS-made estimates for publication will be higher than
    the quality of the estimates generated for research purposes. In
    addition, the BLS-made estimates will reflect a consistent, objective,
    and transparent methodology across all States.
        Upon implementation, this proposal will reinvest a portion of the
    savings from restructuring to improve survey response rates and
    accelerate the rate at which the sample of businesses is refreshed.
    Both of these enhancements will contribute to reducing statistical
    error in the national, State, and area estimates. BLS staff would
    welcome the opportunity to meet to address any other questions on the
    CES restructuring proposal.
        The DOL continues to value Federal-State cooperation in the
    accomplishment of BLS statistical programs. Working through BLS, the
    DOL consults regularly with the State LMI agencies on strategies for
    strengthening and improving the statistical system. The fiscal year
    2011 budget request for BLS includes approximately $80 million in
    support of State operations on the five cooperative statistical
    programs. This amount also includes a request for additional resources
    for one of these programs--Occupational Employment Statistics (OES)--to
    improve the usefulness of OES data for identifying trends in
    occupational employment and wages. In particular, this initiative will
    improve the quality of OES data for State and local decisionmaking on
    investments in education and training programs. Lastly, the Department
    will take the suggestion to review the Federal-State cooperative
    programs into consideration.
                                     ______

                Questions Submitted by Senator Mary L. Landrieu

                         VOLUNTARY PROTECTION PROGRAMS

        Question. Currently, there are more than 100 sites in the Voluntary
    Protection Programs (VPP) in and actively pursuing VPP status in the
    State of Louisiana. Collectively, these sites employ approximately
    24,656 workers.
        How will the proposed shift in the Department of Labor's (DOL)
    Occupational Safety and Health Administration (OSHA) resources from
    compliance assistance to enforcement impact these VPP sites in terms of
    their ability to either obtain or retain VPP their ability to
    participate in the VPP in 2011?
        Answer. OSHA is not eliminating the VPP. However, OSHA is looking
    for other nongovernmental-funded ways to continue the program. Given
    the budgetary issues facing the Nation, the agency is making hard
    choices to use our limited resources where they are most needed.
        As a result, OSHA is reducing Federal resources spent on companies
    that fully understand and exercise their responsibility to protect
    their workers' health and safety to invest resources in companies that
    are not doing a good job protecting their employees. The agency
    recognizes the importance of the, VPP, and participating companies that
    have made a valuable contribution to workplace safety by going above
    and beyond OSHA's requirements and serving as models for others.
        According to Government Accountability Office (GAO) report on the
    VPP published in May 2009, approximately 80 percent of VPP worksites
    have fewer than 500 employees.
        Question. Has OSHA studied and concluded separately on the impact
    on small businesses of the fiscal year 2011 DOL budget proposal to
    shift OSHA resources from compliance assistance to enforcement? What
    are OSHA's plans to review the impact on small businesses that
    participate in the VPP of implementing a user fee system to fund VPP?
        Answer. Currently, 99 of 1,644 Federal VPP sites--or 6 percent of
    the total--meet the small business definition (i.e., 250 or fewer
    employees and not part of a corporation/organization with 500 or more
    employees.) Only 30 percent of all workers are employed in
    establishments larger than 250 employees. In other words, 94 percent of
    VPP sites are part of large companies where only 30 percent of
    Americans work.
        In addition, OSHA's fiscal year 2011 budget includes a $1 million
    increase for the State Consultation Program, which provides free on-
    site consultative services for small businesses that request assistance
    in achieving voluntary employee protection. The Consultation Program is
    particularly useful to small businesses, and the additional funding
    requested in fiscal year 2011 will help meet the demand from small
    employers seeking assistance to come into compliance with OSHA
    requirements
        The May 2009 GAO report found merit in the VPP programs overall,
    but that OSHA had not developed goals or measures to assess the
    performance of the VPP, and the agency's efforts to evaluate the
    program's effectiveness had not been adequate. OSHA generally agreed
    with the GAO report's recommendations to develop procedures and
    measures to assess the performance of the VPP.
        Question. What is the current status of implementing the
    recommendations from the GAO report for assessing the performance of
    the VPP?
        Answer. OSHA is currently reassessing all aspects of the VPP due in
    part to the GAO report of May 2009. At the same time, OSHA is an active
    participant in the Department-wide 2010-2016 strategic planning process
    and is formulating new performance measures for all of its programs.
                                     ______

                    Questions Submitted by Senator Jack Reed

        Question. There are more than 16,000 public libraries in the United
    States, most of which provide job/career information and resources,
    such as access to computers so that patrons can search for jobs and
    file for government services such as unemployment benefits. In the
    economic downturn, libraries are a community resource increasingly in
    demand, especially by those who are unemployed.
        How will the Department of Labor (DOL) work to better integrate
    libraries into our workforce system so that they receive the support
    they need to continue providing these services to the public?
        Answer. DOL, Employment and Training Administration (ETA) has
    entered into a partnership with the Institute for Museum and Library
    Services (IMLS) in recognition of the critical role that both the
    public workforce system and the Nation's public libraries play in
    responding to jobseekers' needs. The goal of the partnership is to
    encourage libraries and the workforce system to collaborate at the
    State and local levels, resulting in increased employment and training
    services to job seekers that lead to good jobs, including career
    pathways and sustainable wages.
        ETA and IMLS are engaged in a number of activities to support
    libraries in meeting the growing employment needs of their patrons. For
    example, ETA has already incorporated libraries and existing co-
    locations between libraries and One-Stop Career Centers into America's
    Service Locator (www.servicelocator.org), an online search tool for
    local service providers. This allows a library patron or job seeker to
    locate the nearest One-Stop Career Center and library within their
    community so that they can access the employment and training services
    they need. ETA is preparing to announce the ETA/IMLS partnership to the
    workforce system, including the announcement of successful
    collaborations between libraries and the public workforce system, and
    to encourage development of such partnerships at the State and local
    levels.
        In addition, ETA has shared information about the employment and
    training resources available through the public workforce system with
    IMLS and its strategic partners. For example, ETA has begun to
    disseminate information about its national electronic tools, including
    CareerOneStop (www.careeronestop.org) and the occupational database
    O*NET (www.onlineonetcenter.org), that provide important career
    information and resources to individual libraries and library systems.
    ETA also plans to conduct a webinar to orient and train librarians and
    other staff to the electronic tools, which are accessible to library
    patrons and other job seekers anytime at any physical location via the
    Internet. Lastly, ETA staff is using library newsletters and other
    dissemination channels to inform the library community about events and
    developments that are relevant to workforce development and this
    partnership.
        In comparison to the more than 16,000 public libraries, there are
    roughly 1,800 federally funded ``One-Stop'' Career Centers under the
    Workforce Investment Act. There is some evidence that the unemployed
    are opting to use their local library for the services that the One-
    Stops are designed to provide due to location or other reasons. It has
    also been reported that some of these centers refer users to their
    local libraries for additional job search assistance. At the same time,
    there are some examples of libraries and local workforce development
    organizations working together to provide help to job seekers, such as
    in North Carolina.
        Question. What are your thoughts on ways we can support and expand
    these collaborations to best serve job seekers?
        Answer. Partnerships between the Nation's public workforce system
    and the library system increases the access points by which job seekers
    can receive critical career information and job assistance. ETA plans
    to announce the existing partnership between ETA and the IMLS at the
    Federal level and encourage partnerships at the State and local levels.
    This will be followed by an ETA-sponsored webinar for the public
    workforce system this summer that showcases promising examples of
    collaboration. Examples of partnership activities to be highlighted
    include:
      --co-locating One-Stop Career Centers and libraries;
      --collaborating to train library staff about employment and training
            resources available through the public workforce system;
      --using library space to provide services to library patrons, (e.g.,
            familiarizing them with career resources offered through the
            public workforce system and available electronically) or to
            host career events (e.g., career fairs); and
      --sharing workforce and labor market information, including data on
            high-growth industries and occupations, from the public
            workforce system to libraries.
        Both ETA and IMLS are engaging their respective systems'
    intergovernmental and other stakeholder organizations to identify
    examples of existing partnership activities that can be widely shared
    with leaders from the workforce and library systems. For example,
    during a National Governors Association event, ETA, IMLS, and workforce
    system and library leaders from the State of North Carolina discussed
    State level partnerships. In addition, ETA is also collaborating with
    the National Association of State Workforce Agencies and the National
    Association of Workforce Boards to identify promising collaborations at
    the State and local levels. Collaborative efforts will include the
    utilization of the Reemployment Works! Community of Practice--a virtual
    community for workforce professionals dedicated to exchanging promising
    practices, tools, and resources for connecting unemployed individuals
    with careers--to disseminate information and strategies about how
    partnerships between the public workforce and library systems can help
    jobseekers find new jobs and enter career pathways.
                                     ______

                  Questions Submitted by Senator Thad Cochran

         WORKFORCE INVESTMENT ACT (WIA) WORKFORCE INNOVATION FUND (WIF)

        Question. WIA provides job training and related services to
    unemployed and underemployed individuals including programs for adults,
    youth, dislocated workers, and others. As part of the partnership for
    WIF with the Department of Education, the budget proposes to reserve 5
    percent of the appropriation for adult and dislocated worker programs
    to form a new WIF and 15 percent of the appropriation for youth
    services to create a Youth Innovation Fund. Innovation funding would
    provide grants to test new practices of expanding and improving
    services and outcomes in the workforce development system and to
    replicate promising or proven workforce strategies, such as
    apprenticeships and on-the-job-training.
        Note: According to the Bureau of Labor Statistics, the seasonally
    adjusted unemployment rate for youth (16-24) nationwide is 18.5 percent
    for February 2010. In Mississippi, the overall unemployment rate is
    10.9 percent (no State data is available specifically for Mississippi
    youth)
        Given the high levels of youth unemployment, why is the Employment
    and Training Administration (ETA) proposing a cut (fiscal year 2011
    compared to fiscal year 2010) in State formula grants for youth
    activities?
        Answer. In fiscal year 2011, the Department of Labor (DOL) is
    requesting $1,025,000,000 to support WIA youth formula activities, an
    increase of $100,931,000 more than the fiscal year 2010 level. The
    fiscal year 2011 target for participants is 306,998, which includes
    266,274 Formula Grant participants and 40,724 Youth Innovation Fund
    participants. This is an increase of 24,572 participants more than the
    fiscal year 2010 target. Fifteen percent ($153.75 million) of the
    request would be dedicated to testing and validating strategies for
    improving service delivery and outcomes for at-risk youth through the
    Youth Innovation Fund. The funds allotted to local workforce areas to
    provide services are not reduced; the 2011 request reduces the State
    reserve from 15 to 10 percent, so the share for local services is
    unaffected.
        The Youth Innovation Fund will fund and rigorously evaluate
    innovative approaches to providing education and employment services to
    at-risk youth, particularly out-of-school youth. It will have two
    components: Summer and Year-Round Employment grants and Work Experience
    Plus grants. The Summer and Year-Round Employment grants will support
    paid work experiences for both in-school and out-of-school youth. The
    Work Experience Plus grants will allow local workforce investment
    boards, working in partnership with youth service providers, Governors
    and State workforce boards, to test innovative approaches for serving
    out-of-school youth in a comprehensive manner, combining work
    experience, education, and support services. Work Experience Plus
    programs will seek to help youth disconnected from education and from
    work move into postsecondary education leading to industry-based
    credentials, degrees, and employment. DOL expects that the Youth
    Innovation Fund ultimately will provide for more effective use of WIA
    formula funds through innovation and learning about what works for at-
    risk youth.
        Question. Are the proposed innovation grants multi-year grants and
    would they require funding in subsequent years?
        Answer. In fiscal year 2011, DOL envisions the Innovation Fund
    grants would be competitively awarded as multi-year grants. DOL
    believes multi-year grants are needed to allow adequate time to test
    and evaluate the innovative models and approaches that the Innovation
    Funds are designed to encourage. The Innovation Funds are proposed as a
    means of driving reform and continuous improvement, encouraging
    cooperation across programs and regions, and allowing the
    identification and replication of evidence-based approaches. DOL looks
    forward to working with Congress to support the Innovation Funds in WIA
    reauthorization and in subsequent years.
        Question. If these proposed innovation grants are intended as
    multi-year grants, what are the proposed periods (e.g., 3 years, 5
    years)?
        Answer. DOL anticipates that the Innovation Fund grants will be
    multi-year grants, generally of up to 3 years. A multi-year approach
    offers grantees sufficient time to test their approaches, allow for
    flexibility where needed, and provide DOL with sufficient time to carry
    out a review or evaluation of the grant and other administrative
    responsibilities, such as grant close-out activities.

                                   JOB CORPS

        Question.
        In prior years, DOL indicated that the appropriations for
    construction would be used to improve the condition of facilities at
    Job Corps centers. Specifically, DOL would place emphasis on the
    backlog of repairs on existing buildings and disposal of ``surplus,
    nonmission-dependent properties.''
        What are the specific program efficiencies DOL is seeking to
    improve?
        Answer. The Office of Job Corps expects to improve efficiencies in
    several areas. For example, we will use a multi-pronged approach to
    reduce increasing utility and fuel costs. The program is reducing its
    General Services Administration vehicle fleet, and replacing
    traditional vehicles with alternative energy-efficient electric
    vehicles for use on centers. Construction projects funded under the
    American Recovery and Reinvestment Act (ARRA) have included energy
    efficient upgrades that will reduce utilities costs at Job Corps center
    facilities. To complement these efforts, we have implemented a
    nationwide energy conservation campaign, funded by ARRA, which promotes
    the adoption of green practices by students and staff. Further, our new
    Job Corps centers are being built to Leadership in Energy and
    Environmental Design specifications and will be state-of-the-art,
    energy-efficient facilities.
        Job Corps also is working to maximize centers' slot capacity
    utilization. The program anticipates an increase in students' average
    length of stay as a result of our rigorous career technical training
    system that includes industry-focused foundation courses for new
    students and the incorporation of industry-recognized certifications.
    Students must remain in the program longer to complete these program
    requirements. This increased retention will reduce costly student
    turnover.
        Finally, Job Corps is exploring ways to decrease the cost of large
    scale on-center services, such as basic medical care and prescription
    drugs, without compromising the quality or provision of these services
    to students. The program also will evaluate its discretionary national
    office support contracts for possible reduction or conversion to
    Federal staff.
        Question. How will DOL determine whether the benefits gained from
    transferring funds to operations will be greater than the benefits lost
    from less construction and renovation?
        Answer. With the majority of shovel-ready projects already funded
    by the Recovery Act, the program anticipates no material loss to
    construction and renovation. In fact, over the coming months, Job Corps
    will be undergoing a large design phase to prepare construction
    projects for launch. Any decision to transfer funding would be preceded
    by a thorough review of the relative costs and benefits.

                          FOREIGN LABOR CERTIFICATION

        Question. What specific steps is DOL taking to detect and deter
    fraud in the foreign labor certification process?
        Answer. Within the ETA, the Office of Foreign Labor Certification
    (OFLC) undertakes a number of steps to both detect and deter fraud in
    the programs for which it has responsibility. These actions vary by
    visa program depending upon specific authorities, e.g. statutory and
    regulatory authorizations available to the OFLC. Many ``triggers'' or
    ``flags'' are built into application processing systems, both
    electronically and manually, in order to detect and prevent fraud from
    occurring.
        Examples of specific actions include: (1) validating that the
    application OFLC receives was submitted by that employer and not
    someone fraudulently filing in their name; (2) verifying employer
    Federal Employer Identification Numbers; and (3) checking debarment
    tables, and other internal measures. In addition, OFLC extensively uses
    its audit authority and a request for information process when
    questions and/or concerns arise about an application, an employer, or
    its representative. Frequently applications are placed into audit when
    there are concerns about the availability of U.S. workers for the
    requested position, employer responses which trigger an audit, e.g.,
    recruitment period not consistent with program requirements, etc. When
    and wherever appropriate, OFLC utilizes its debarment and revocation
    authority as additional means of insuring program integrity. OFLC also
    participates in the ongoing investigation and where necessary,
    prosecution of individuals involved in suspected instances of fraud.
    OFLC, along with DOL 's Wage and Hour Division, participates in Office
    of Inspector General investigations, provides expert testimony at grand
    jury trials, as well as contribute to other Federal agency
    investigations.
        Question. Employers wishing to hire foreign workers often express
    frustration with the labor condition application (LCA) process and
    describe it as unresponsive to their need to hire people expeditiously.
        What are the current backlogs, if any, by visa type, and what is
    the average ``turn-around'' time to process LCAs?
        Answer. ETA's OFLC administers four major foreign labor
    certification programs:
      --Permanent Labor Certification Program (PERM or the Green Card)
      --H-1B Specialty Occupations Program (LCAs)
      --H-2A Temporary Agricultural Program
      --H-2B Temporary Non-Agricultural Program
        The table below displays the application process and current case
    processing times for each of these programs. The Immigration and
    Nationality Act specifically requires the Secretary of Labor, prior to
    granting a labor certification, to insure that the employment of the
    foreign worker will not adversely impact the wages and working
    conditions of similarly employed U.S. workers. The OFLC also must
    determine there are no available U.S. workers for the requested
    position. These statutory obligations mean that to provide America's
    workers with opportunities to access jobs there is greater scrutiny of
    occupations and employers with pending applications in labor markets
    impacted by the layoffs.
        In November 2009, ETA initiated an intensive effort designed to
    reduce PERM's backlog of cases. Its goal for fiscal year 2010 is to
    reduce the backlog by 50 percent to approximately 35,000 cases. We are
    on schedule, and we will continue this effort as part of our larger DOL
    commitment to customer service.

                                   TABLE 1A.--ETA OFLC VISA CASE PROCESSING REPORT, FISCAL YEAR 2010 (THROUGH MARCH 31, 2010)
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                       Total applications processed                                       Active workload
                                     -----------------------------------------------------------------------------------------------------------------------
              Visa category                                                                                                                 Average ``turn
                                          Totals         Certified        Denied         Withdrawn     Pending cases        Backlog          around'' time
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    PERM............................          40,299          35,051           3,809           1,439          48,306  Yes...............  11 months
    H-1B............................         152,630         127,201          20,834           4,595           7,031  No................  4-5 days
    H-2B............................           3,199           2,738             461  ..............             120  No................  16 days
    H-2A............................           3,415           2,961              76              78             334  No................  22 days
                                     -----------------------------------------------------------------------------------------------------------------------
          Fiscal year 2010 grand             199,243         167,951          25,180           6,112          55,791
           total.
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Source: Administrative records extracted from the ETA-OFLC Case Management Systems.

        Question. The U.S. economy entered into a recession in December
    2007. Although some economic indicators suggest that growth has
    resumed, unemployment remains high and is projected to remain so for
    some time. Since 2008, how many LCAs has DOL approved annually?
        Answer. The following table displays case processing information
    for fiscal year 2008, fiscal year 2009, and 50 percent of the year for
    fiscal year 2010. With the exception of the H-1B Program (excluded by
    statute), all of the programs have required ``testing'' of the local
    labor market prior to the approval and granting of labor certification
    to insure domestic workers are fully considered for the job
    opportunity.

                   TABLE 1B.--ETA OFLC SUMMARY REPORT, FISCAL YEAR 2008-2010 (THROUGH MARCH 31, 2010)
    ----------------------------------------------------------------------------------------------------------------
                              Visa category                                2008            2009          2010 \1\
    ----------------------------------------------------------------------------------------------------------------
    PERM:
        Cases processed.............................................          61,997          38,247          40,299
        Cases certified.............................................          49,205          29,502          35,051
        Workers requested...........................................         ( \2\ )         ( \2\ )         ( \2\ )
        Workers certified...........................................         ( \2\ )         ( \2\ )         ( \2\ )
    H-1B:
        Cases processed.............................................         369,381         263,243         152,630
        Cases certified.............................................         368,958         266,230         127,201
        Workers requested...........................................         654,871         438,273         360,104
        Workers certified...........................................         651,762         483,203         225,146
    H-2B:
        Cases processed.............................................          11,177           7,090           3,199
        Cases certified.............................................          10,257           5,871           2,738
        Workers requested...........................................         292,645         218,274          79,091
        Workers certified...........................................         250,343         154,489          61,192
    H-2A:
        Cases processed.............................................           8,096           8,150           3,115
        Cases certified.............................................           7,944           7,665           2,961
        Workers requested...........................................          86,113         103,955          65,753
        Workers certified...........................................          82,078          86,014          53,349
    ----------------------------------------------------------------------------------------------------------------
    Source: Administrative records extracted from the ETA-OFLC Case Management Systems.

    \1\ Includes cases processed from October 1, 2009 through March 31, 2010.
    \2\ Not applicable. A permanent ``green card'' application only contains one named beneficiary.

        Question. For the PERM Program, the decrease in case certifications
    from fiscal year 2008 to fiscal year 2009 is attributable, in large
    measure to the following reasons:
      --Inadequate number of Federal staff to perform final case
            adjudications.
      --Increased integrity measures implemented, e.g., the number of cases
            placed in audit, supervised recruitment. The declining state of
            the economy especially U.S. worker availability in conjunction
            with employer layoff data prompted increased scrutiny of
            applications especially those filed by employers who were
            experiencing layoffs.
      --The state of the economy did affect the nature and number of H-2B
            filings. Further, changes in the regulations implementing both
            the H-2A and H-2B influenced filing patterns.
        Question. Would you please provide these statistics by occupation,
    trade group and visa category?
        Answer. The table below entitled ``Top 10 PERM Occupations, fiscal
    year 2008-2010'' illustrates the top 10 occupations for which employers
    requested workers by type of visa for each of the 3 fiscal years (thru
    March 31, 2010). OFLC does not collect data by trade group, so that is
    not included. Because nearly all positions certified under the H-2A
    visa program involve the planting, cultivating, and harvesting of
    fruits and vegetables, more than 98 percent of workers are employed in
    the occupation of ``Farmworker Laborer, Fruits and Vegetables.''

               TABLE 1D.--ETA OFLC TOP 10 H-1B OCCUPATIONS, FISCAL YEAR 2008-2010 (THROUGH MARCH 31, 2010)
    ----------------------------------------------------------------------------------------------------------------
                                                       Applications    Applications       Workers         Workers
                     Top occupation                      processed       certified       requested       certified
    ----------------------------------------------------------------------------------------------------------------
                    FISCAL YEAR 2008

    Computer systems analysis and programming.......         183,162         183,462         380,299         379,864
    Architectural occupations.......................           4,251           4,360          27,234          26,436
    College and university occupations..............          23,159          23,192          24,843          24,810
    Other computer related occupations..............          19,361          19,405          23,326          23,278
    Accountant, auditors, and related occupations...          14,515          14,550          23,063          22,990
    Budget and management occupations...............           7,776           7,797          21,333          21,367
    Electrical engineering occupations..............          13,531          13,583          16,979          16,853
    Physicians and surgeons.........................           9,359           9,400          13,693          13,598
    Data communications and network occupations.....           4,741           4,756          12,630          12,613
    Secondary school education occupations..........           4,007           4,028           9,286           9,167

                    FISCAL YEAR 2009

    Computer systems analysis and programming.......         107,858         108,349         233,742         238,039
    Budget and management occupations...............           5,569           5,620          38,348          38,721
    Other computer related occupations..............          12,470          12,551          18,617          18,510
    Architectural occupations.......................           2,140           2,172          17,316          16,301
    College and university occupations..............          16,076          16,132          16,655          16,597
    Accountant, auditors, and related occupations...          10,542          10,667          16,482          16,357
    Electrical engineering occupations..............           8,926           8,987          11,104          10,980
    Physicians and surgeons.........................           7,740           7,804          10,600          10,500
    Miscellaneous managers and officials............           5,403           5,451           6,932           6,884
    Miscellaneous professional, technical, and                 5,014           5,062           6,466           6,418
     managerial occupations.........................

                  FISCAL YEAR 2010 \1\

    Computer software engineers, applications.......          14,396          12,675          75,773          20,547
    Computer programmers............................          17,740          15,936          54,693          52,354
    Software quality assurance engineers and testers           1,059             940          53,601           1,470
    Computer systems analysts.......................          16,451          14,835          45,599          43,275
    Computer software engineers, systems software...           7,216           6,629          10,180           9,445
    Physicians and surgeons, all other..............           2,589           2,196           4,785           3,398
    Financial analysts..............................           3,813           3,097           4,572           3,791
    Market research analysts........................           3,804           2,654           3,934           2,771
    Management analysts.............................           2,934           2,348           3,932           3,287
    Physical therapists.............................           2,241           1,924           3,808           3,352
    ----------------------------------------------------------------------------------------------------------------
    Source: Administrative records extracted from the ETA-OFLC Case Management Systems.

    \1\ Includes cases processed from October 1, 2009 through March 31, 2010.

               TABLE 1E.--ETA OFLC TOP 10 H-2B OCCUPATIONS, FISCAL YEAR 2008-2010 (THROUGH MARCH 31, 2010)
    ----------------------------------------------------------------------------------------------------------------
                                                       Applications    Applications       Workers         Workers
                     Top occupation                      processed       certified       requested       certified
    ----------------------------------------------------------------------------------------------------------------
                    FISCAL YEAR 2008

    Landscape laborer...............................           3,458           3,375          79,223          76,383
    Housekeeping, cleaner...........................             724             689          23,984          22,442
    Construction worker I...........................             610             572          16,591          14,618
    Forest worker...................................             121             114          12,983          12,416
    Amusement park worker...........................             152             150           7,322           7,262
    Welder fitter...................................              57              30           6,785           2,466
    Housekeeper.....................................             203             192           6,537           5,829
    Waiter/waitress.................................             166             158           5,030           3,961
    Dining room attendant...........................             213             208           4,451           4,325
    Tree planter....................................              49              46           4,371           4,187

                    FISCAL YEAR 2009

    Landscape laborer...............................           2,030           1,793          55,840          48,315
    Forest worker...................................             128             113          13,606          11,375
    Welder fitter...................................              78               1          11,916              30
    Housekeeping, cleaner...........................             325             277          10,381           8,256
    Construction worker I...........................             341             273           9,170           6,185
    Housekeeper.....................................             279             240           9,097           6,392
    Amusement park worker...........................             132             129           7,571           6,783
    Industrial commercial groundskeeper.............             224             208           5,363           4,840
    Horse stable attendant..........................             320             265           4,095            3510
    Welder, combination.............................              30  ..............           3,378  ..............

                  FISCAL YEAR 2010 \1\

    Landscape laborer...............................           1,041             986          25,337          22,184
    Industrial commercial groundskeeper.............             207             189           5,624           4,598
    Amusement park worker...........................             108             104           4,928           4,754
    Housekeeper.....................................             196             173           4,821           3,590
    Housekeeping, cleaner...........................             134             103           3,614           2,121
    Construction worker I...........................             111              87           3,417           2,056
    Forest worker...................................              54              37           3,313           1,725
    Landscape specialist............................              49              48           1,511           1,332
    Horse stable attendant..........................              66              59           1,365           1,004
    Waiter/waitress.................................              69              64           1,125           1,027
    ----------------------------------------------------------------------------------------------------------------
    Source: Administrative records extracted from the ETA-OFLC Case Management Systems.

    \1\ Includes cases processed from October 1, 2009 through March 31, 2010.

                  FEDERAL UNEMPLOYMENT BENEFITS AND ALLOWANCES

        Question. What is the current backlog of determination decisions?
    How long does it currently take to reach determinations on trade
    adjustment assistance (TAA) petitions?
        Answer. In the first 90 days under the Trade and Globalization
    Adjustment Assistance Act of 2009 (TGAAA), TAA received more than 2,300
    petitions for assistance. The initial petition filings created the
    backlog that TAA has systemically reduced on a weekly basis.

        There are currently 835 cases that have been under investigation
    for more than 40 days; the average backlogged case is 133 days overdue.
    The time taken to reach a decision is steadily decreasing as DOL works
    through the remainder of the petition backlog.
        Question. How did DOL prepare for the sharp increase in petitions?
    Has DOL hired additional investigators?
        Answer. DOL began preparing for the anticipated increase in program
    petitions immediately after the President signed the ARRA containing
    the TGAAA. At that time, DOL had about 20 Federal staff and 14 contract
    staff working in the TAA program. Those staff included staff focused on
    petition investigations, program policy, funding, data collection and
    management, and office support.
        The TGAAA significantly expanded the TAA program which resulted in
    an increase in petition filings of 104 percent from fiscal year 2008 to
    fiscal year 2009. While the ARRA reauthorized and expanded the program,
    it did not contain any funding specifically for the Federal
    administration of TAA. DOL used departmental management funds included
    in the ARRA to fund staffing and other TGAAA implementation costs.
        Using these ARRA funds and other existing DOL resources, the DOL's
    ETA began a major hiring effort. As of March 2010, ETA had 28 permanent
    Federal staff and 20 ARRA-funded temporary Federal staff working on the
    TAA program. Of the 48 current program staff, 42 currently focus on
    petition investigations and the associated data management and
    notification process, while 6 focus on delivery of services, program
    policy, funding, correspondence and data collection, and management.
    Additionally, ETA has nine contract staff providing support to the TAA
    office.
        Question. What are DOL's plans to reduce the backlog of petitions?
        Answer. In addition to the intensive hiring effort undertaken by
    ETA, DOL has implemented an office realignment strategy to more
    effectively and efficiently address the TAA petition backlog. This
    strategy includes better TAA petition management; more equally balanced
    team and management structures; and incorporated a specialized team of
    investigators tasked with quickly resolving the most difficult cases.
    DOL also secured the assistance of a TAA investigation expert to help
    examine different and effective strategies within the current
    investigative process. Through this study, DOL identified areas to
    improve the petition investigation process and has implemented changes
    that are leading to more efficient case investigations. As a result,
    DOL has reduced the backlog by 37 percent since the beginning of
    January 2010. DOL continues to explore hiring options to ensure
    efficient staff planning and preparation for attrition of staff as a
    result of the expiration of ARRA-funded positions on September 30,
    2010. As part of its planning for the loss of staff, DOL has requested
    an increase of 16 full-time equivalents for the TAA program in fiscal
    year 2011.
        Question. How many petitions has DOL certified from firms that
    would not have been eligible for TAA benefits prior to the expansion of
    the program? How many workers have been certified in the period since
    the expansion compared to the same time period prior to the expansion?
        Answer. Under the TGAAA, TAA has certified more than 2,300
    petitions and certified an estimated 255,000 workers from May 18, 2009
    to April 12, 2010. The same time-period in the previous year, TAA
    certified 1,561 petitions and 153,463 estimated workers.

                       TAA CERTIFICATIONS UNDER THE 2009 AMENDMENTS (MAY 18, 2009-APRIL 12, 2010)
    ----------------------------------------------------------------------------------------------------------------
                                                                                                         Estimated
                                                                         Number of     Percentage of     number of
                                                                      certifications  certifications      workers
    ----------------------------------------------------------------------------------------------------------------

                          PRIMARY CERTIFICATION

    Company imports of articles.....................................             185            7.94          24,017
    Company imports of services.....................................              37            1.59           2,540
    Customer imports of articles....................................             315           13.53          40,363
    Customer imports of services....................................              22             .94           4,565
    Imports of finished articles containing like or directly                       7             .3              591
     competitive components.........................................
    Imports of finished articles containing foreign components......               3             .13             124
    Imports of articles produced using worker services..............               4             .17             345
    Increased aggregate imports.....................................              69            2.96           9,243
    Shift in production.............................................             730           31.34          96,100
    Acquisition of articles from a foreign country..................              89            3.82           7,674
    Shift in services...............................................             357           15.33          17,515
    Acquisition of services from a foreign country..................             106            4.55           6,916
    Public agency...................................................  ..............  ..............  ..............
    ITC determination...............................................              20             .86           5,813

                         SECONDARY CERTIFICATION

    Secondary component supplier....................................             283           12.15          33,554
    Secondary service supplier......................................              74            3.18           3,098
    Downstream producer.............................................              28            1.2            2,980
                                                                     -----------------------------------------------
          Totals....................................................           2,329          100            255,438
    ----------------------------------------------------------------------------------------------------------------

        The certification rate under the TGAAA is about 82 percent compared
    to 70 percent prior to the TGAAA. While DOL cannot quantify the number
    of workers that would have been denied prior to the expansion, the
    increase in the certification rate is attributable to the expansions in
    the service sector in the TGAAA. Prior to the TGAAA workers who
    performed services could be certified, but only when associated with
    the production of an article; the TGAAA allows for stand-alone service
    sector certifications and includes other smaller expansions. In fiscal
    year 2008, workers not producing an article caused the greatest numbers
    of TAA denials.
        Question. What is the administration's position on reauthorizing
    the TAA program when it expires on December 31, 2010?
        Answer. The administration supports the reauthorization of the TAA
    program, including continuing the expansions to the program contained
    in the TGAAA, and included reauthorization in the 2011 President's
    budget.

                  OFFICE OF LABOR-MANAGEMENT STANDARDS (OLMS)

        Question. OLMS administers and enforces provisions of the Labor-
    Management Reporting and Disclosure Act. This Act requires that labor
    unions, which represent private sector employees, file financial
    disclosure reports with OLMS and make those reports available to union
    members. The Act also established minimum standards for elections to
    choose union officers.
        In fiscal year 2010, the administration requested, and Congress
    approved, an 8 percent reduction in the budget for OLMS. For fiscal
    year 2011, the administration requests a $3.8 million increase but the
    majority is for computer modernization. The fiscal year 2011 request
    would keep the number of employees at 269--the same level as the
    current fiscal year. This is well below the 298 employed at the agency
    in fiscal year 2009.
        How has the reduction in staffing since fiscal year 2009 affected
    the enforcement of union reporting requirements?
        Answer. OLMS is fully funded and is well-positioned to maintain and
    improve upon its historically strong enforcement record. OLMS continues
    to improve targeting of audits and ensuring increased internal process
    efficiency in order to bring the best cases to protect union members'
    rights. In fact, OLMS' fiscal year 2009 enforcement numbers clearly
    demonstrate an increase in the number of criminal investigations,
    conviction levels, and delinquent report investigations, as compared to
    fiscal year 2008.

    ------------------------------------------------------------------------
                                                Fiscal year     Fiscal year
              Enforcement activity                 2008            2009
    ------------------------------------------------------------------------
    Election complaint investigations.......             130             129
    Supervised re-run elections.............              35              32
    Election complaints resolved (figure                  35              32
     represents both agreements and
     lawsuits)..............................
    Criminal investigations.................             393             404
    Indictments.............................             131             122
    Convictions.............................             103             120
    Compliance audits.......................             798             754
    Delinquent report investigations........           2,019           2,596
    Deficient investigations................             799             749
    ------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal year     Fiscal year     Fiscal year
                          Enforcement activity                          2008, first     2009, first     2010, first
                                                                           half            half            half
    ----------------------------------------------------------------------------------------------------------------
    Election complaint investigations...............................              50              60              72
    Supervised re-run elections.....................................              16              19              10
    Election complaints resolved (figure represents both agreements               10              15              17
     and lawsuits)..................................................
    Criminal investigations.........................................             181             184             154
    Indictments.....................................................              70              52              59
    Convictions.....................................................              53              55              56
    Compliance audits...............................................             353             360             246
    Delinquent report investigations................................             721             845             968
    Deficient report investigations.................................             375             343             255
    ----------------------------------------------------------------------------------------------------------------

        At the midpoint of fiscal year 2008 and fiscal year 2009,
    delinquent and deficient report investigations were roughly comparable
    to the midyear fiscal year 2010 figure, shown above in the far right
    column. Specifically, as of March 31, 2009, OLMS recorded 845
    delinquent report investigations and 343 deficient report
    investigations. As of March 31, 2008, the figures were 721 and 375,
    respectively.
        Question. For the last fiscal year, how many unions have not filed
    their financial disclosure forms?
        Answer. OLMS estimates that 25,378 Labor Organization Annual
    Financial Reports were due in fiscal year 2009. Not all unions use the
    same fiscal year beginning and ending dates; slightly less than two-
    thirds use a January 1-December 31 fiscal year. To conform the
    different fiscal year beginning and ending dates with the Federal
    fiscal year dates, we here include unions whose fiscal year ended on or
    after 10/1/2008 but on or before 9/30/2009. Because the reports are not
    actually due until 90 days following the close of the union's fiscal
    year, the 25,378 total reflects all unions who would owe OLMS a report
    sometime during fiscal year 2009. As of April 19, 2010, approximately
    860 labor unions had not filed the fiscal year 2009 report.
        Question. How will DOL ensure that OLMS remains independent now
    that the office reports directly to the Secretary?
        Answer. Effective November 8, 2009, the umbrella organization known
    as the Employment Standards Administration (ESA) ceased to exist. DOL
    had decided to abolish ESA while maintaining the four component
    programs (the Wage and Hour Division, OLMS, the Office of Federal
    Contract Compliance Programs, and the Office of Workers' Compensation
    Programs) as stand-alone organizations, reporting directly to the
    Secretary of Labor. This move greatly improved the visibility and
    access of the four agencies to the Secretary, facilitating improved
    communication and more efficient operations. OLMS, as the previous
    statistics clearly demonstrate, remains committed to a robust
    enforcement program.

                                 BUDGET DEFICIT

        Question. In fiscal year 2009, the Federal budget deficit was $1.4
    trillion. The administration is projecting a deficit of $1.6 trillion
    for fiscal year 2010. The administration has requested a 3 percent
    increase in discretionary funding for DOL for fiscal year 2011 (up from
    $13.5 billion to $14 billion). While the administration proposes some
    program eliminations and program reductions, they do not offset the
    proposed increases in the budget.
        What are the DOL's long-term plans to slow or reduce the increase
    in discretionary spending?
        Answer. DOL is working within the administration's direction to
    freeze discretionary nonsecurity spending for 3 years. As such, we
    continue to examine how to focus limited resources on achieving results
    for DOL. We are currently developing a new strategic plan for DOL that
    implements my strategic vision of ``Good Jobs for Everyone''. We have
    established outcome goals that support this vision and are currently
    developing performance goals. As we determine our resource needs,
    having these goals will help us develop responsible budget requests
    within the President's direction. We are also looking at what programs
    are not working or do not clearly support my vision. Consistent with
    applicable law, resources will be shifted from these ineffective
    programs to those that are proven to work.
        Ultimately, DOL's plan is to invest in improving jobs for America's
    workforce. As unemployment decreases, so does the administrative costs
    of the unemployment insurance program. As worker pay increases, so
    rises the resources to reduce our reliance on borrowing to balance the
    Federal budget. In short, our focus on ``Good Jobs for Everyone'' is an
    investment that will help reduce discretionary spending as well as
    speed the Nation's economic recovery.
        Question. What are DOL's plans to improve the efficiency and
    effectiveness of programs administered by DOL?
        Answer. DOL is requesting $14 billion in discretionary funding for
    fiscal year 2011, a reduction of $299 million (3 percent) below the
    fiscal year 2010 discretionary budget of $14.3 billion. In fiscal year
    2011, DOL will implement a new evaluation program that will rebuild
    DOL's evaluation capacity and support a rigorous evaluation agenda that
    measures the efficiency and effectiveness of programs and interventions
    and informs policy, management, and resource allocation decisions.
        The new evaluation program will be headed by a Chief Evaluation
    Officer (CEO) who will be responsible for developing a comprehensive
    DOL evaluation program that ensures that research and evaluation are
    aligned with DOL's performance goals and strategic vision. The CEO will
    assist agencies in preparing their annual research and evaluation plans
    and provide technical assistance in project design and analysis.
        In fiscal year 2010, resources are being allocated to evaluations
    that improve the effectiveness of Government through evidenced-based
    research. The highest priority has been given to impact evaluations, or
    evaluations aimed at determining the causal effects of programs.
        In fiscal year 2011, DOL received $40.3 million to fund five
    rigorous evaluations and demonstration of workplace safety enforcement
    and workforce development services. Many of these evaluations will
    employ random assignment methods and others will use the most rigorous
    empirical methods available.
        In keeping with the President's vision of a transparent and
    accountable Government, DOL will publish all final reports from program
    evaluations in a timely manner.
                                     ______

                 Question Submitted by Senator Mitch McConnell

        Question. Given the high rate of unemployment within the veteran's
    population, what is the Department of Labor (DOL) doing to help ensure
    that these brave service members are able to find jobs when they return
    to civilian life?
        Answer. The Veterans' Employment and Training Service (VETS) is
    playing a leadership role within the DOL to assist returning service
    members in their transition back to civilian life. To leverage the
    broader range of resources available across DOL, VETS is undertaking
    new initiatives in partnership with other Federal and DOL agencies.
    They include:
      --Applying Priority of Service to Leverage Enhanced Resources.--In
            partnership with the Employment and Training Administration
            (ETA), VETS is emphasizing that the recently published Final
            Rule on Priority of Service for veterans and eligible spouses
            is to be applied to the enhanced services delivered by ETA
            under the funding provided through the American Recovery and
            Reinvestment Act (ARRA).
      --Initiating a Redesign of Transition Assistance Program (TAP)
            Employment Workshops.--VETS, in partnership with the Department
            of Defense and the Department of Veterans Affairs, has
            exercised lead responsibility over the past 25 years for the
            employment workshops offered under TAP. VETS recently undertook
            an internal review of the employment workshop component of TAP
            and concluded that this set of services will benefit from an
            external review, with an eye to redesigning the curriculum. A
            contract for the external review and redesign is expected to be
            awarded during this fiscal year.
      --Partnering With Job Corps for Younger Veterans.--In partnership
            with the ETA's Office of Job Corps, VETS is taking new
            initiatives to offer younger veterans at risk of unemployment
            the opportunity for referral to Job Corps Centers. This
            initiative will take advantage of VETS' access to separating
            service members at TAP employment workshops.
      --Stimulating Employment Opportunities for Veterans.--VETS is
            undertaking a major outreach initiative to employers. The
            Assistant Secretary for Veterans' Employment and Training has
            convened an employer summit, established a relationship with
            the U.S. Chamber of Commerce, and has assigned VETS' field
            staff to conduct outreach activities with employers operating
            at the State and local levels.
      --Improving Customer Service to Returning Veterans Facing Issues With
            Employers.--To improve customer service to veterans who file
            complaints under the Uniformed Services Employment and
            Reemployment Rights Act (USERRA), VETS developed a Web-based
            tutorial for nationwide dissemination and streamlined some
            burdensome, paper-oriented aspects of this program. The
            tutorial is an interactive instruction with video clips to
            increase service member's and employer awareness with respect
            to service member's rights under the USERRA.
      --Refocusing the Jobs for Veterans State Grants.--With participation
            by ETA, VETS is emphasizing increased delivery of intensive
            services by Disabled Veterans' Outreach Program specialists and
            increased conduct of employer outreach and job development
            activities by Local Veterans' Employment Representative (LVER)
            staff.
      --Capitalizing on New Work Opportunity Tax Credit Incentives.--In the
            reauthorization of the Work Opportunity Tax Credit (WOTC) and
            in the recent authorization of ARRA, Congress enhanced the
            opportunities for veterans to benefit from the incentives
            available to employers under WOTC. In partnership with ETA,
            VETS is developing strategies to empower LVER staff to assist
            veterans in gaining pre-certification for WOTC.
      --Enhancing and Expanding Outreach Through Electronic Media.--VETS
            has re-engineered the Agency's Web site, has conducted a Web-
            based outreach session with key stakeholders and has applied
            social networking for enhanced outreach to veterans.
      --Bridging the Gap With Rural Communities.--VETS has taken steps to
            leverage existing rural outreach networks in an effort to
            overcome the geographic and cultural barriers separating
            veterans in remote locations from mainstream work
            opportunities.
      --Strengthening Veteran Opportunities Among Federal Contractors.--
            VETS is supporting the efforts of the Office of Federal
            Contract Compliance Programs to revise the regulations
            governing affirmative action by Federal contractors in the
            hiring of targeted veteran groups, so that the Federal
            contractors' responsibilities are more clearly specified.

                              SUBCOMMITTEE RECESS

        Senator Harkin. The subcommittee will stand recessed.
        [Whereupon, at 9:52 a.m., Tuesday, March 23, the hearing
    was adjourned 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 APPROPIATIONS FOR FISCAL YEAR 2011

                                  ----------

                           WEDNESDAY, APRIL 14, 2010

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:34 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Landrieu, Reed, Pryor, Cochran,
    Shelby, and Alexander.

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    STATEMENT OF HON. ARNE DUNCAN, SECRETARY

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. Good morning. The Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies will now come to order.
        Secretary Duncan, welcome back to the subcommittee. You and
    I have had many occasions to talk recently, both here and in my
    home State, about the reauthorization of the Elementary and
    Secondary Education Act (ESEA).
        As you know, we are in the process of holding several
    reauthorization hearings in the Health, Education, Labor and
    Pensions (HELP) Committee--not in this subcommittee, in the
    HELP Committee--and I share your commitment to completing that
    work this year.
        But today, we are here to talk specifically about funding.
    This is the Appropriations Committee. When it comes to
    resources, it is a time of both great promise and great peril.
    While the books on fiscal year 2010 won't be closed for another
    6 months, we can already safely predict that the Federal
    Government will spend far more money on education this year
    than in any other year in history.
        Between the regular 2010 appropriations bill and last
    year's American Recovery and Reinvestment Act (ARRA), the
    Education Department will provide more than $100 billion to
    States, districts, and higher education programs across the
    country this year. The State Fiscal Stabilization Fund (SFSF)
    in particular has been one of the great success stories of the
    ARRA. That funding is currently supporting more than 300,000
    education jobs across the country and certainly helped to
    mitigate the effects of the recession.

                   STUDENT AID AND FISCAL RESPONSIBILITY ACT

        Last month, we also celebrated the passage of the Student
    Aid and Fiscal Responsibility Act. This landmark legislation
    eliminated wasteful corporate subsidies in the Federal student
    loan program and strengthened the Pell Grant program.

               FISCAL YEAR 2011 BUDGET REQUEST INCREASE OVER 2010

        The President's proposed education budget for fiscal year
    2011 also holds promise. As we all know, the President's budget
    holds the line on nonsecurity-related spending overall in
    fiscal year 2011, but the President pledged to use a scalpel
    and not an ax to achieve the freeze, and the Department of
    Education is one of the Federal agencies that would receive an
    increase of 7.5 percent more than in fiscal year 2010.

                               EDUCATION LAYOFFS

        Despite these positive developments for Federal funding of
    education, there are many danger signs. That is because the
    bottom has fallen out for State and local funding in many
    communities across the country, just as the funding for the
    SFSF begins to wind down in September of this year. Every day
    brings more reports about a massive wave of layoffs that could
    soon strike school districts and institutions of higher
    education.
        Based on estimates we are seeing so far, the number of pink
    slips for educators could easily top 100,000 this fall. Job
    cuts of this magnitude would, of course, have a devastating
    impact on families across the country and could stall the
    Nation's economic recovery. But they would also take a terrible
    toll on our education system.
        Large numbers of layoffs mean bigger class sizes, fewer
    program offerings, less time for students to learn in school.
    It is hard to see how you can get this kind of education reform
    that you, Mr. Secretary, and Senators on this subcommittee want
    to achieve if schools are cutting their instructional time.

                        KEEP OUR EDUCATORS WORKING BILL

        That is why later today I will introduce a bill--the Keep
    Our Educators Working Act. This bill will create a $23 billion
    education jobs fund that will provide money to every State for
    the specific purpose of hiring or retaining school employees
    next year--teachers, principals, librarians, counselors,
    custodians, and so on.
        And we must act soon. We must act soon. As I said, the
    money that we had in the ARRA, that was for 2 years, expires
    September 30 of this year. We know that there are pink slips
    already going out, maybe as many as 100,000 or more.
        But right now, we have to act because State departments of
    education and local school boards are already making their
    decisions. They are making their decisions this month in April
    and in May about what they have to do next year. This is not
    something that we can fix in August. We have to fix it now. And
    that is why I will do everything I can to bring up on the floor
    of the Senate as soon as possible this $23 billion funding
    bill.
        Now, why is it $23 billion? Well, it is about 50 percent of
    what was in the ARRA. The ARRA provided for 2 years. We are
    just looking at this as a 1-year shot for next year, and so it
    is about 50 percent of what we had in the ARRA.
        So I just say to you, Mr. Secretary, we are going to do
    everything we can, and I am going to ask for your help and the
    President's help in getting this done. As I said, time is of
    the essence here.

                              PELL GRANT SHORTFALL

        Now, another danger on the horizon is the Pell shortfall.
    Again, during tough economic times, more students and more
    financially needy students seek a higher education. That can
    lead to a temporary funding shortfall in the Pell program. And
    one of the relatively unheralded accomplishments of the student
    reconciliation bill was the inclusion of significant funding to
    address that shortfall.
        I want to personally thank you publicly, Mr. Secretary, for
    working so hard with us to provide those funds. But we are
    still about $5.7 billion short in the Pell Grant program. If we
    don't find a way to make up the difference, every program in
    our appropriations bill and even programs in other agencies
    could suffer.
        So I am hoping we can continue to work with the
    administration to fight for the rest of the Pell funding in the
    upcoming spending bill that we will be reporting out of this
    subcommittee. And so, we will talk more about those issues
    soon, but I first want to turn to Senator Cochran for any
    opening remarks that he would like to offer.

                       STATEMENT OF SENATOR THAD COCHRAN

        Senator Cochran. Mr. Chairman, thank you very much for
    convening this hearing when we review the observations and
    statement of the distinguished Secretary of Education.
        The President has submitted a budget request to the
    Congress, and it is our obligation to review the request and
    consider the opinions of those who are involved in education
    and who have responsibilities for administering the Federal
    programs supporting education in our country. So it is a very
    important responsibility, and this subcommittee is going to
    work hard to try to make sure that we provide the funding that
    is needed to help ensure that our students throughout the
    country have opportunities to learn and prosper.
        And that is the purpose of our hearing today, to get an
    overview of the budget and to make sure that we are going to do
    the right thing in supporting these activities administered by
    Secretary Duncan and his able staff members.
        But you know we really owe a great deal of thanks to the
    teachers and the administrators throughout the country who
    really are at the point where the action occurs and where the
    responsibilities are discharged that make a big difference in
    the lives of our students. So, with that in mind, we are happy
    to have you before the subcommittee, Mr. Secretary, and we
    invite you to proceed to make whatever comments you think will
    be helpful to our understanding of the budget request.
        Senator Harkin. Thank you. Thank you very much, Senator
    Cochran.
        Arne Duncan became the ninth Secretary of the U.S.
    Department of Education on January 20, 2009. Before his
    appointment, Secretary Duncan served as the chief executive
    officer of the Chicago Public Schools. Before serving in
    Chicago, he ran the Ariel Education Initiative, which covered
    college costs for a group of inner-city youth, and was
    instrumental in starting a new public elementary school which
    ranks among the top schools in Chicago.
        Secretary Duncan, a graduate of Harvard University, welcome
    again to the subcommittee. And Mr. Secretary, your statement
    will be made a 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, Vice Chairman
    Cochran, members of the subcommittee.

              STATE AND LOCAL LEVEL EDUCATION CUTBACKS AND LAYOFFS

        I plan to begin today by talking about education reform
    because there is a lot of good news to report, but before I do,
    I want to talk about education jobs. We are gravely concerned
    that the kind of State and local budget threats our schools
    face today will put our hard-earned reforms at risk.
        Every day, every single day brings media reports of
    layoffs, program cuts, class time reductions, and class size
    increases. None of this is good for children. Here is just a
    sample in some of your States.
        Mr. Chairman, you and I recently visited schools in Iowa,
    which just announced 1,500 layoffs, half of them teachers. In
    Ames, they are reducing full-day kindergarten to half day and
    delaying textbook purchases.
        In my home State of Illinois, they are looking at cutting
    20,000 teaching jobs. In California and New York, they have
    also announced more than 20,000 job cuts each. I think the
    superintendent of Los Angeles is testifying before this
    committee later today.
        Schools in Jackson, Mississippi, are increasing class size,
    while public colleges in neighboring Louisiana are canceling
    summer classes in the face of $300 million in budget cuts over
    the next 2 years.
        I recently read there are some schools in Kansas that have
    gone to a 4-day school week, and Hawaii began Friday furloughs
    earlier this year. New Jersey surveyed more than 300 school
    districts, and two-thirds are cutting sports, bands, and clubs.
    Many are also dropping after-school summer programs.
        Charlotte, North Carolina, will cut 600 teachers next year.
    Appleton, Wisconsin, is losing 50 positions, mostly teachers,
    while one district in Washington State is cutting 10 percent of
    its teaching workforce.
        In a survey of school administrators, one-third of them say
    they may have to cut summer school despite compelling research
    showing that summer learning loss amongst low-income students
    is a significant contributor to the achievement gap.

               IMPACT OF LAYOFFS AND CUTBACKS ON OVERALL ECONOMY

        While there is no hard number yet for the entire country,
    we think the State budget cuts could imperil anywhere from
    100,000 to 300,000 education jobs. That not only creates
    hardships for hard-working educators who lose their jobs and
    the children they teach, but the damage ripples through the
    economy as a whole.
        The layoffs would create a new drag on the economy when,
    despite the recent encouraging jobs reports, we still have a
    long way to go. Literally, tens of millions of students will
    experience these budget cuts in one way or another. Moreover,
    schools, districts, and States that are working so hard to
    improve will see their reforms undermined by these budget
    problems.

                       COMMITMENT TO IMPROVING EDUCATION

        The financial crisis facing public education is coming at
    an especially crucial moment for America. We are more focused
    than ever before on the importance of education to our economy
    and more committed than ever before to challenging ourselves to
    get better.
        There is a broad consensus that we must invest at every
    level--from early childhood through college--to help the next
    generation succeed and compete in our global economy. There is
    a deep commitment from stakeholders across the spectrum that
    education is one issue that absolutely can bring us together.
    And at every level of our education system, there is
    groundbreaking work underway to improve the way we teach and
    learn.

                          STATE EDUCATIONAL STANDARDS

        Forty-eight States are working together to raise education
    standards across the country because they understand we must
    better prepare our children for college and careers. No more
    dumbing down standards due to political pressure. No more lying
    to children.
        Let me be clear. This is a State-led movement. These are
    not Federal standards.

                          RACE TO THE TOP COMPETITION

        States are also preparing for phase two of the Race to the
    Top competition. This $4 billion program, which represents less
    than 1 percent of K-12 education funding nationally, has
    prompted States and stakeholders to sit down together and have
    the kind of difficult, but necessary conversations that have
    never happened before.
        The results, in a word, are stunning, even before money has
    gone out the door. Legal barriers to reform have been
    eliminated, progressive labor agreements have been forged, and
    new partnerships have emerged around bold and far-reaching
    plans. By one count, 26 States have passed laws to strengthen
    their education reform agendas. No one is defending the status
    quo.
        And there is enormous demand for the program. Forty States
    and the District of Columbia applied in phase one, requesting,
    collectively, $13 billion. We expect at least the same amount,
    if not more applications in phase two. And this is just one of
    our competitive programs.

              STATE IMPROVEMENT GRANTS AND INVESTING IN INNOVATION

        Thanks to School Improvement Grants provided by Congress in
    the last two budgets and the ARRA, educators across America are
    also confronting the toughest challenge in education, which is
    fixing their lowest-performing schools. Thanks to the Investing
    in Innovation program (i3), that was also created by Congress
    through the ARRA, school districts, foundations, and community
    partners are developing innovative new learning models to take
    into our classrooms and our schools.
        We expect as many as 2,500 applications, and we know that
    we will have at least 2 applications from every State. The
    entire country is looking to drive innovation at the local
    level, where we must take to scale what is working.

                  TRAINING, RETAINING, AND RECRUITING TEACHERS

        Today, our colleges of education are rethinking how they
    train teachers for the classrooms of tomorrow. States,
    districts, and schools are rethinking how they recruit,
    support, and evaluate teachers in order to strengthen their
    profession. Teachers deserve better mentoring and professional
    development than they receive today.

                           ACCESS TO HIGHER EDUCATION

        And today, millions more young people are getting grants to
    attend college, thanks to the leadership of the President and
    Congress and the historic decision to shift billions of dollars
    from bank subsidies for student loans to help low-income
    students pay for college.
        Mr. Chairman, this would never have happened without your
    leadership. And I want you to know how much that means to me
    personally.

            ESEA REAUTHORIZATION AND FISCAL YEAR 2011 BUDGET REQUEST

        All of this work has been accelerated by your leadership
    and your collective commitment to children and education. And
    with your leadership, we want to do much more to support this
    work at the local level. Our proposed ESEA blueprint is defined
    by three words--fair, flexible, and focused.
        We want to create a fair system of accountability that
    instead of stigmatizing schools and educators rewards them for
    excellence. We want to focus on growth and gain rather than
    absolute test scores. Rather than dictating one-size-fits-all
    solutions, we want to give States and districts more
    flexibility to improve the vast majority of schools that may
    have challenges, but by no measure are failing.
        And third, we want to focus resources and support on
    students most at risk in chronically low-performing schools and
    schools with ongoing large achievement gaps.

                           GOALS OF REFORM STRATEGIES

        Our 2011 budget request supports continuing formula funding
    for low-income and special education students and teachers and
    principals, as well as students learning English and other
    diverse populations of children from rural to migrant to
    homeless. But we also know that too many children at risk today
    are not well served by the status quo, which is why I want to
    continue driving reform with competitive programs.
        All of our reform strategies have two goals--to raise the
    bar for all students and to close the achievement gap. We have
    to create better opportunities for students who need them the
    most. So with our budget request, we hope to continue Race to
    the Top, the Investing in Innovation Fund, and programs to get
    great teachers and principals into schools and classrooms where
    they are needed the most. To close the achievement gap, we must
    get serious about closing the opportunity gap.

                         EARLY LEARNING CHALLENGE FUND

        Mr. Chairman, I know that you and others worked tirelessly
    to include the Early Learning Challenge Fund in the student
    lending bill, and I thank you for that. Given that it
    ultimately was not included, we want to work with you to bring
    it back because we must do more to help students start school
    ready to succeed. That investment in early childhood education
    may be the best long-term investment we as a Nation can make.

                              STUDENT AID FUNDING

        Two other unmet needs are the remaining shortfall in the
    Pell Grant program and the increased administrative costs
    associated with the shift to 100 percent direct lending.
        I greatly appreciate the Senate leadership in helping cover
    the Pell shortfall in the reconciliation bill. Now I want to
    work with Congress to address the remainder of the shortfall
    through a supplemental appropriation or other appropriate
    measure to avoid putting pressure on other critical education
    programs.

               ADMINISTRATIVE COST OF 100 PERCENT DIRECT LENDING

        Last, given that we are now assuming 100 percent of the
    student loan portfolio, we must strengthen our student lending
    operation to ensure that the student aid program is efficient
    and our private contracts are well-managed. Most of the
    additional money we are requesting will support private loan
    servicing contracts.
        I want to salute Congress on both sides of the aisle for
    embracing our responsibility to our children and investing in
    education. Thanks to all of you, we have entered an exciting
    new era of educational reform, progress, and opportunity.

                                      ARRA

        I also ask you to consider the looming budget threat that
    could put all of this at risk. The ARRA dollars given to the
    Department of Education helped save an estimated 400,000 jobs
    at the State and local level, mostly in education, but also in
    public safety and other areas of critical need. It was the
    right thing to do, and it proved that fiscal relief is an
    effective way to create economic activity and jobs.

                 NEED FOR ADDITIONAL EMERGENCY EDUCATION FUNDS

        The final round of funding is now making its way to State
    capitals and school districts and to college students through
    Pell Grants, but it is not nearly enough to avert the
    catastrophe unfolding across the country. And so, today, on
    behalf of Governors, mayors, educators, students, parents,
    business leaders, community leaders, and everyone who shares
    the view that education is the key to our economic strength and
    civic vitality, I urge Congress to consider another round of
    emergency support for America's schools.
        If we do not help avert this State and local budget crisis,
    we could impede reform and fail another generation of children.
    The fact is that gaps for special education, low-income, and
    minority students remain stubbornly wide. All of you know the
    reality of the challenges that our students and, therefore, our
    Nation face today. We must confront this reality with honesty,
    courage, and a commitment to challenge the status quo.

                          COLLEGE AND CAREER READINESS

        One in four, 1 in 4 of our high school students today fails
    to graduate. Forty percent of students who go on to college
    need remedial education. They are not actually ready. And huge
    numbers of young people determined to go to college and pursue
    a career drop out because of financial or academic challenges.
        If we want reform to move forward, we need an education
    jobs program. Jobs and reform go hand in hand. It is difficult
    to improve the quality of education while losing teachers,
    raising class size, eliminating days of instruction,
    eliminating after-school and summer-school programs. Our
    children, particularly disadvantaged children, desperately need
    more time, not less.

                               PREPARED STATEMENT

        Teachers work very hard, and the vast majority of them give
    their heart and soul to their profession. They are heroes in
    every sense of the word, and we need to support them,
    especially because we are asking more of them. The status quo
    in education is not good enough. We must all get better. Our
    children need it, and our future demands it.
        Thank you so much. I am now happy to take any questions you
    might have.
        [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 the President's 2011 budget request
    for education. I want to begin by thanking all of you for your
    commitment to our children's education. This subcommittee has played a
    critical role in helping the Department to accomplish an extraordinary
    amount of work over the past year, both to help America's education
    system weather the economic recession and to launch key initiatives to
    improve the quality of that system.
        It was just more than a year ago that Congress and President Obama
    worked together to complete the American Recovery and Reinvestment Act
    of 2009 (Recovery Act). This legislation is delivering nearly $100
    billion in education funding to Recovery Act recipients, including
    States and school districts, to help address budget shortfalls in the
    midst of the most severe financial crisis and economic recession since
    the Great Depression. To date, the Department has awarded more than $69
    billion. For the quarter ending December 31, 2009, recipients reported
    that assistance from the Department of Education funded approximately
    400,000 jobs overall, including more than 300,000 education jobs, such
    as principals, teachers, librarians, and counselors. These numbers are
    consistent with the data submitted in October, during the first round
    of reporting, and this consistency reflects the steady and significant
    impact of the Recovery Act. Although State and local education budgets
    remain strained, schools systems throughout the country would be facing
    much more severe situations were it not for the Recovery Act. The
    Recovery Act also increased Federal postsecondary student aid to help
    students and families pay for college.
        I believe that the Recovery Act did much more than just provide
    short-term financial assistance to States and school districts. Indeed,
    I think the Recovery Act will be seen as a watershed for American
    education because it also laid the groundwork for needed reforms that
    will help improve our education system and ensure America's prosperity
    for decades to come. Thanks to the Recovery Act, all States now are
    working to strengthen their standards and assessments, improve teacher
    and leader effectiveness, improve data systems and increase the use of
    data to improve instruction, and turn around low-performing schools.
        In addition, the Recovery Act helped to jumpstart a new era of
    innovation and reform, particularly through the $4 billion Race to the
    Top Program and the $650 million Investing in Innovation Fund. Many
    States already have demonstrated their interest in Race to the Top by
    making essential changes, such as allowing data systems to link the
    achievement of individual students to their teachers and enabling the
    growth or expansion of high-quality charter schools, and on March 29 we
    were pleased to announce the first two Race to the Top awards to
    Delaware and Tennessee. Both of these States submitted applications
    demonstrating a successful track record, bold reforms, broad buy-in,
    and statewide impact. Tennessee capitalized on its value-added
    assessment system as the foundation for future reforms, while Delaware
    is building on its Vision 2015 blueprint. Both States also secured
    broad support through a combination of changing their State laws and
    coalition-building among school districts, unions, businesses, advocacy
    groups, and local philanthropies. I am confident that other States will
    draw on these lessons to submit even stronger applications during the
    second phase of the Race to the Top competition this summer.
        States also are demonstrating the progress they have made toward
    implementing the reforms called for in the State Fiscal Stabilization
    Fund in their applications for phase II of that funding. We must
    continue to invest in innovation and scale up what works to make
    dramatic improvements in education. The President's fiscal year 2011
    budget requests $1.35 billion for Race to the Top awards, both for
    States and for a new school district-level competition, as well as $500
    million in additional funding for the Investing in Innovation (i3)
    Program.
        Most recently, I want to thank all of the members of the
    subcommittee who supported the Health Care and Education Reconciliation
    Act, which President Obama signed into law on March 30, 2010. This
    legislation will allow the Department to make much-needed reforms to
    Federal postsecondary student loan programs that will save an estimated
    $68 billion over the next 11 years. These savings will be redirected
    toward a more generous and fiscally stable Pell Grant program, lowering
    the cost of student loans, improving our community college system, and
    increasing support for Historically Black Colleges and Universities and
    other minority-serving institutions.

                     PRESIDENT OBAMA'S 2011 BUDGET REQUEST

        The centerpiece of the 2011 budget request for the Department of
    Education is the pending reauthorization of the Elementary and
    Secondary Education Act (ESEA). The President is asking for a
    discretionary increase of $3.5 billion for fiscal year 2011, of which
    $3 billion is dedicated to ESEA, the largest-ever requested increase
    for ESEA. Moreover, if Congress completes an ESEA reauthorization that
    is consistent with the President's plan, the administration will submit
    a budget amendment for up to an additional $1 billion for ESEA
    programs. We would greatly appreciate your support for this historic
    budget.
        The Department's budget and performance plan for 2011 also includes
    a limited number of high-priority performance goals that will be a
    particular focus over the next 2 years. These goals, which will help
    measure the success of the Department's cradle-to-career education
    strategy, reflect the importance of teaching and learning at all levels
    of our education system. The Department's goals include turning around
    struggling schools, improvements in the quality of teaching and
    learning, implementation of comprehensive statewide data systems, and
    simplifying student aid. These goals and other performance information
    are included in the President's fiscal year 2011 budget materials and
    are on www.ed.gov.

            FISCAL YEAR 2011 BUDGET REQUEST AND ESEA REAUTHORIZATION

        Our 2011 budget request incorporates an outline of our key
    principles and proposals for ESEA reauthorization. These proposals are
    explained in more detail in our ``Blueprint for Reform,'' which was
    released on March 13, 2010 and which also is available at www.ed.gov.
    We have thought a great deal about the appropriate Federal role in
    elementary and secondary education, and want to move from a simple
    focus on rules, compliance, and labeling of insufficient achievement,
    toward a focus on flexibility for States and local educational agencies
    (LEAs) that demonstrate how they will use program funds to achieve
    results, and on positive incentives and rewards for success. That is
    why, for example, our 2011 budget request includes $1.85 billion in new
    funding for the Race to the Top and i3 Programs. In addition, our
    reauthorization proposal for title I, part A of ESEA would reward
    schools or LEAs that are making significant progress in improving
    student outcomes and closing achievement gaps. Our budget and
    reauthorization proposals also would increase the role of competition
    in awarding ESEA funds to support a greater emphasis on programs that
    are achieving successful results.
        We believe that our goals of providing greater incentives and
    rewards for success, increasing the role of competition in Federal
    education programs, supporting college- and career-readiness, turning
    around low-performing schools, and putting effective teachers in every
    classroom and effective leaders in every school require a restructuring
    of ESEA program authorities. For this reason, our budget and
    reauthorization proposals would consolidate 38 existing authorities
    into 11 new programs that give States, LEAs, and communities more
    choices in carrying out activities that focus on local needs, support
    promising practices, and improve outcomes for students, while
    maintaining Federal support for the most disadvantaged students,
    including dedicated formula grant programs for students who face unique
    challenges, such as English learners, homeless children, migrant
    students, and neglected and delinquent students.

                          COLLEGE AND CAREER READINESS

        Another key priority is building on the Recovery Act's emphasis on
    stronger standards and high-quality assessments aligned with those
    standards. We believe that a reauthorized title I program, which our
    budget request would fund at $14.5 billion, should focus on graduating
    every student college- and career-ready. States would adopt standards
    that build toward college- and career-readiness, and implement high-
    quality assessments that are aligned with and capable of measuring
    individual student growth toward these standards. To support States in
    this effort, our request would provide $450 million, an increase of 10
    percent, for a reauthorized Assessing Achievement program (currently
    State assessments).
        States would measure school and LEA performance on the basis of
    progress in getting all students, including groups of students who are
    members of minority groups, from low-income families, English learners,
    and students with disabilities, on track to college- and career-
    readiness, as well as in closing achievement gaps and improving
    graduation rates for high schools. States would use this information to
    differentiate schools and LEAs and provide appropriate rewards and
    supports, including recognition and rewards for those showing progress
    and required interventions in the lowest-performing schools and LEAs.
    To help turn around the Nation's lowest-performing schools, our budget
    would build on the $3 billion in school improvement grants provided in
    the Recovery Act by including $900 million for a School Turnaround
    Grants Program (currently School Improvement Grants). This and other
    parts of our budget demonstrate the principle that it is not enough to
    identify which schools need help--we must encourage and support State
    and local efforts to provide that help.

                     EFFECTIVE TEACHERS AND SCHOOL LEADERS

        We also believe that if we want to improve student outcomes,
    especially in high-poverty schools, nothing is more important than
    ensuring that there are effective teachers in every classroom and
    effective leaders in every school. Longstanding achievement gaps
    closely track the inequities in classrooms and schools attended by poor
    and minority students, and fragmented ESEA programs have failed to make
    significant progress to close this gap. Our reauthorization proposal
    will ask States and LEAs to set clear standards for effective teaching
    and to design evaluation systems that fairly and rigorously
    differentiate between teachers on the basis of effectiveness and that
    provide them with targeted supports to enable them to improve. We also
    will propose to restructure the many teacher and teacher-related
    authorities in the current ESEA to more effectively recruit, prepare,
    support, reward, and retain effective teachers and school leaders. Key
    budget proposals in this area include $950 million for a Teacher and
    Leader Innovation Fund, which would support bold incentives and
    compensation plans designed to get our best teachers and leaders into
    our most challenging schools, and $405 million for a Teacher and Leader
    Pathways Program that would encourage and help to strengthen a variety
    of pathways, including alternative routes, to teaching and school
    leadership careers.
        We also are asking for $1 billion for an Effective Teaching and
    Learning for a Complete Education authority that would make competitive
    awards focused on high-need districts to improve instruction in the
    areas of literacy, science, technology, engineering, mathematics, the
    arts, foreign languages, civics and government, history, geography,
    economics and financial literacy, and other subjects. Our request also
    includes $2.5 billion for an Effective Teachers and Leaders formula
    grant program to help States and LEAs improve teaching and enhance the
    teaching profession.
        In addition, throughout our budget, we have included incentives for
    States and LEAs to use technology to improve effectiveness, efficiency,
    access, supports, and engagement across the curriculum. In combination
    with the other reforms supported by the budget, these efforts will pave
    the way to the future of teaching and learning.

                            IMPROVING STEM OUTCOMES

        One area that receives special attention in both our 2011 budget
    request and our reauthorization plan is improving instruction and
    student outcomes in science, technology, engineering, and mathematics
    (STEM). The world our youth will inherit will increasingly be
    influenced by science and technology, and it is our obligation to
    prepare them for that world.
        The 2011 request includes several activities that support this
    agenda and connect with President Obama's ``Educate to Innovate''
    campaign, which is aimed at fostering public-private partnerships in
    support of STEM. Our goal is to move American students from the middle
    of the pack to the top of the world in STEM achievement over the next
    decade, by focusing on (1) enhancing the ability of teachers to deliver
    rigorous STEM content and providing the supports they need to deliver
    that instruction; (2) increasing STEM literacy so that all students can
    master challenging content and think critically in STEM fields; and (3)
    expanding STEM education and career opportunities for underrepresented
    groups, including women and girls and individuals with disabilities.
        Specifically, we are asking for $300 million to improve the
    teaching and learning of STEM subjects through the Effective Teaching
    and Learning: STEM Program; $150 million for STEM projects under the
    $500 million request for the i3 Program; and $25 million for a STEM
    initiative in the Fund for the Improvement of Postsecondary Education
    to identify and validate more effective approaches for attracting,
    retaining, engaging, and effectively teaching undergraduates in STEM
    fields. In addition, I have directed the Department to work closely
    with other Federal agencies, including the National Science Foundation,
    the Department of Defense, the National Aeronautics and Space
    Administration, and the National Institutes of Health to align our
    efforts toward our common goal of supporting students in STEM fields.

                            COMPREHENSIVE SOLUTIONS

        We also recognize that schools, parents, and students will benefit
    from investments in other areas that can help to improve student
    outcomes. Toward that end, we are proposing to expand the new Promise
    Neighborhoods Program by including $210 million in our budget to fund
    school reform and comprehensive social services for children in
    distressed communities from birth through college and career. A
    restructured Successful, Safe, and Healthy Students Program would
    provide $410 million to--for the first time--systematically measure
    school climates, which we know can affect student learning. This will
    help direct funding to schools that show the greatest need for
    resources to increase students' safety and well-being by reducing
    violence, harassment and bullying; promote student physical and mental
    health; and prevent student drug, alcohol, and tobacco use.

                         COLLEGE ACCESS AND COMPLETION

        The administration has made college- and career-readiness for all
    students the goal of its ESEA reauthorization proposal, because most
    students will need at least some postsecondary education to compete for
    jobs in the 21st century global economy. For this reason, we are
    proposing a College Pathways and Accelerated Learning Program that
    would increase high school graduation rates and preparation for college
    by providing students in high-poverty schools with opportunities to
    take advanced coursework that puts them on a path toward college. This
    new program would help expand access to accelerated learning
    opportunities such as Advanced Placement and International
    Baccalaureate courses, dual-enrollment programs that allow students to
    take college-level courses and earn college credit while in high
    school, and ``early college high schools'' that allow students to earn
    a high school degree and an associate's degree or 2 years of college
    credit simultaneously.
        Just as essential to preparing students for college is ensuring
    that students and families have the financial support they need to pay
    for college. We took a giant step toward this goal with the passage of
    the Health Care and Education Reconciliation Act, which will make key
    changes in student financial aid and higher education programs that are
    consistent with President Obama's goal of restoring America's status as
    first in the world in the percentage of college graduates by 2020. In
    combination with the Reconciliation Act, the 2011 request would make
    available more than $156 billion in new grants, loans, and work-study
    assistance--an increase of $58 billion, or 60 percent, more than the
    amount available in 2008--to help almost 15 million students and their
    families pay for college. And another achievement of the Recovery Act,
    the new American Opportunity Tax Credit, will provide an estimated $12
    billion in tax relief for 2009 filers. The budget proposes to make this
    refundable tax credit permanent, which will give families up to $10,000
    to help pay for 4 years of college.
        The Reconciliation Act also will invest more than $40 billion in
    Pell Grants to ensure that all eligible students receive an award and
    that these awards are increased in future years to help keep pace with
    rising college costs. Beginning in 2013, the act will provide annual
    increases based on the change in the Consumer Price Index that are
    expected to raise the maximum Pell award from $5,550 in 2013 to $5,975
    in 2017. In addition, by the 2020-2021 academic year, the number of
    Pell Grant recipients is expected to grow by more than 820,000.
        Finally, the Reconciliation Act will allow postsecondary students
    enrolling in 2014 or later, and who obtain a Federal student loan, to
    limit their monthly loan payments to 10 percent of their discretionary
    income, down from the previous requirement of 15 percent of income.
    More than 1 million borrowers will be eligible to reduce their monthly
    payments, and to obtain forgiveness of all remaining student loan debt
    after 20 years of payments, or just 10 years for public service workers
    such as teachers or nurses or those in military service.

                     IMPROVING OUTCOMES FOR ADULT LEARNERS

        The 2011 budget request includes funding for a variety of programs
    that support adult learners, including career and technical education,
    and adult basic and literacy education. These programs provide
    essential support for State and local activities that help millions of
    Americans develop the knowledge and skills they need to reach their
    potential in the global economy. For example, our request would provide
    $1.3 billion for Career and Technical Education State Grants to support
    continued improvement and to increase the capacity of programs to
    prepare high school students to meet State college and career-ready
    standards. One of our greatest challenges is to help the 90 million
    adults for whom increasing basic literacy skills is a key to enhancing
    their career prospects. For this reason, we are asking for $612.3
    million for Adult Basic and Literacy Education State Grants, an
    increase of $30 million more than the comparable 2010 level, to help
    adults without a high school diploma or the equivalent to obtain the
    knowledge and skills necessary for postsecondary education, employment,
    and self-sufficiency.

                IMPROVING OUTCOMES FOR PERSONS WITH DISABILITIES

        The budget also includes several requests and new initiatives to
    enhance opportunities for students and other persons with disabilities.
    For example, we are proposing a $250 million increase for Grants to
    States under the Individuals with Disabilities Education Act to help
    ensure that students with disabilities receive the education and
    related services they need to prepare them to lead productive,
    independent lives. The $3.6 billion request for Rehabilitation Services
    and Disability Research would consolidate nine Rehabilitation Act
    programs into three to reduce duplication and improve the provision of
    rehabilitation and independent living services for individuals with
    disabilities. The request includes a $6 million increase more than the
    2010 level for a new Grants for Independent Living Program (which
    consolidates Independent Living State Grants and Centers for
    Independent Living) and would provide additional funding for States
    with significant unmet needs. It also includes $25 million for a new
    program that would expand supported employment opportunities for youth
    with significant disabilities as they transition from school to the
    workforce, through competitive grants to States to develop innovative
    methods of providing extended services.
        The budget provides $112 million for the National Institute on
    Disability and Rehabilitation Research to support a broad portfolio of
    research and development, capacity-building, and knowledge translation
    activities. And the request includes $60 million--$30 million under
    Adult Education and $30 million under Vocational Rehabilitation--for
    the Workforce Innovation Fund, a new initiative in partnership with the
    Department of Labor. The proposed Partnership for Workforce Innovation,
    which encompasses $321 million of funding in the Departments of
    Education and Labor, would award competitive grants to encourage
    innovation and identify effective strategies for improving the delivery
    of services and outcomes for beneficiaries under programs authorized by
    the Workforce Investment Act. This investment will create strong
    incentives for change that, if scaled-up, could improve cross-program
    delivery of services and outcomes for beneficiaries of programs under
    the Workforce Investment Act.

                                   CONCLUSION

        In conclusion, we have made extraordinary progress in meeting the
    needs of our schools and communities in the midst of financial crisis
    and recession, making long-needed reforms in our Federal postsecondary
    student aid programs, and reawakening the spirit of innovation in our
    education system from early learning through college. The next step to
    cement and build on this progress is to complete a fundamental
    restructuring of ESEA, and we believe strongly that our 2011 budget
    request is essential to that effort. I look forward to working with the
    subcommittee toward that goal and have every confidence that with your
    continuing leadership and strong support from President Obama and the
    American people, we will accomplish this important task.
        Thank you. I would be happy to answer any questions you may have.

                              EDUCATION JOBS BILL

        Senator Harkin. Mr. Secretary, thank you for a very
    eloquent statement.
        I can't agree with you more. The status quo is not
    acceptable, and it is not acceptable during economic downturns
    to say that we are just going to take a lot of this out of the
    hide of education. You only get one chance at that, and if we
    fail our kids, that means we fail our future.
        So I am encouraged by your, I think, statement of support
    for a jobs, an education jobs bill. I mentioned the one that I
    am putting in today. I hope that we can count on your active
    support and the support of the administration in getting this
    emergency funding through because it is an emergency. And so,
    again, I hope we can count on your support for that. You
    mentioned that, and I appreciate it.
        Secretary Duncan. Yes, I appreciate your leadership so
    much. We absolutely need a jobs bill, and I look forward to
    working with you to work on the details of it.
        This is the right thing for the country. It is the right
    thing for the economy. It is the right thing for our children.

                 DEFINING AND FUNDING EARLY LEARNING EDUCATION

        Senator Harkin. Absolutely. And we will consult with you on
    how best to get that done and structure it.
        You also mentioned something else, the early learning part
    of the bill that we didn't get in reconciliation because of a
    budget problem that we had, but something that you know I care
    very deeply about. It is one I talk about all the time, that we
    are always playing catch-up ball. And one of the reasons we
    play so much catch-up is that we don't put a lot of emphasis on
    the time when kids' brains are developing the most, and that is
    from birth to 5.
        As you heard me say before, I said it yesterday at a
    hearing at the HELP Committee, that perhaps we ought to rethink
    that elementary education starts at birth. It doesn't start
    when you get to kindergarten. Maybe it starts when you are
    born.
        That is not my statement. That was a statement made by the
    Committee on Education Development in 1991 that was set up by
    President Reagan to look at what we needed in education. It was
    a committee of business people. I guess President Reagan wanted
    the business community to tell us what we needed in education.
        Well, the committee met during the ensuing years after
    that. And finally, in 1991, they came out with a report. I was
    chairman of this subcommittee at that time. And James Renier,
    the head of Honeywell, presented that report to us. And mind
    you, here are some of the biggest business leaders in America,
    heads of big corporations, taking a look at education and what
    was needed. And their executive summary was very simple. It
    said we must remember that education begins at birth and that
    preparation for education begins before birth.
        The whole report was focused on early childhood learning.
    This is 1990, 1991. Twenty-one years later, we are still trying
    to figure out what to do on education. We have got to put more
    into early learning.

                 FUNDING FOR EARLY CHILDHOOD EDUCATION IN 2010

        So, again, we are going to do everything we can in this
    budget cycle. I know it is not in your budget because you were
    probably counting on the money being in the reconciliation
    bill, which got knocked out. So, Mr. Secretary, I hope that we
    can count on working with you to find ways of getting that
    money back in our budget cycle for even as early as next year
    and working with us on that.
        Secretary Duncan. We have to. And that is exactly right. We
    didn't include it in our budget because we thought it was
    coming in through the other source.
        But let me tell you, Mr. Chairman, I would like to work
    with you to adjust our proposed budget. And we think we cannot
    walk away from this. This is the most important thing we can
    do, and so we want to figure out some ways with you to adjust
    our proposed fiscal year 2011 budget so that we can invest in
    early childhood education. We can't afford not to do that.
        Senator Harkin. Well, I can tell you I have had
    conversations with my counterpart on the House side concerning
    this issue and with you, and I look forward to working with you
    to see how we can shoehorn this in some way.
        Secretary Duncan. Our staff is working on a couple
    different options, and we should come back to you shortly with
    a proposal or two.
        Senator Harkin. I appreciate that very much.

                          RACE TO THE TOP COMPETITION

        Mr. Secretary, one thing I would just like to cover before
    I move on, and that is the whole Race to the Top issue. There
    has been a lot of debate, on, yes, Race to the Top. You have
    got a lot of money focused on grants to specific States when
    even as you pointed out in your comments, that whole structure
    is in danger right now.
        And so, the question has been raised to me as should we
    focus that kind of money on a few specific States that may win
    a competition, or do we need to focus this more on the broader
    structural basis of education?
        I think you partially answered that when you said that this
    is about 1 percent, if I am not mistaken. I think you said
    about 1 percent of the total education funding. So when put in
    that context, it gives more credence to this Race to the Top.
        Can you just tell us more of your thoughts on that and how
    we respond to the idea that, because of the structural
    problems, how can we focus on the Race to the Top?
        Secretary Duncan. It is a great question. I just think,
    frankly, we have to walk and chew gum at the same time. So we
    need to save jobs, absolutely. But we need reform as well. And
    these two things go hand in hand. They reinforce each other.
        If we are simply trying to preserve the status quo, we need
    to do that, but that is not going to get us where we need to
    go. We have a dropout rate that is unacceptable. We have far
    too many students who do graduate who aren't actually prepared
    for college or careers. And so, we need to make sure we don't
    go south and get worse, and that is what we are concerned about
    with the huge budget cuts that States and districts are looking
    at.

                                  DROPOUT RATE

        At the same time, we have to be pushing very hard to get
    better, and we have to get that dropout rate down to zero
    absolutely as fast as we can. There are no good jobs out there
    today in the legal economy for a high school dropout. There are
    almost no good jobs out there if you just have a high school
    diploma. You have to have some form of training beyond that--4-
    year universities, 2-year community colleges, trade, technical,
    vocational training.

                            RACE TO THE TOP FUNDING

        And so, we have to get better. We invest as a country each
    year approximately $650 billion in K to 12 education, $650
    billion. Race to the Top, at $4 billion, is less than 1 percent
    of national spending on education, and I think I can make a
    pretty good case to you that the amount of change we have seen
    around the country due to that less than 1 percent investment
    has been extraordinary.
        And we look forward in this next round to seeing more
    States win and benefit. We think States that go through the
    process are getting better and stronger, and they are having
    those conversations that haven't happened historically. And so,
    we hope we have a much larger set of winners in the second
    round. And as you know, we are coming back in the fiscal year
    2011 budget, we want to do a third round of Race to the Top and
    get to that next set of States. And so, this is an ongoing
    evolutionary process.
        But to see the amount of change that has happened with a
    very small amount of money I think is simply extraordinary. We
    had high hopes going in, and it has far exceeded our wildest
    expectations. And so, these are not--these ideas are not in
    conflict. These are false dichotomies. We have to do both.
        We have to make sure we don't go south. We have to make
    sure we are not seeing hundreds of thousands of people laid
    off. But we need to push for real, dramatic, transformational
    change at the same time.
        Senator Harkin. Mr. Secretary, I appreciate that answer.
    You are right. We have got to do both, and we can't let up on
    one or the other.
        Senator Cochran.

                  RURAL AND LOW-INCOME SCHOOL DISTRICT FUNDING

        Senator Cochran. Mr. Chairman.
        Mr. Secretary, I noticed, looking through the summary of
    the request from the administration, that we are not seeing the
    increases requested for some of the programs that are targeted
    to low-income and poverty families whose students live in the
    rural areas of the country, the small towns. And I am
    disappointed in that.
        For example, my State has the highest percentage of
    students who qualify for the benefits of the title I program.
    Only the District of Columbia has a higher percentage than the
    students in our State. And I am worried that the budget request
    submitted by the administration sort of freezes that in place
    and doesn't provide for increases in formula grants under the
    title I program, for instance.
        And so, the schools and the communities with the highest
    numbers of poor students are going to continue to be held back
    and suffer in comparison with the resources that are being made
    available to students in the wealthier and larger cities of the
    country. Does this call for another look at the budget and with
    some emphasis being placed on improving and enlarging the
    amount of money going to these poor school districts, or are
    they going to be locked into last place forever?

                        SCHOOL IMPROVEMENT GRANT FUNDING

        Secretary Duncan. That is the last thing we would want,
    Senator. And you may know through the School Improvement Grants
    Program, which is going to the lowest-performing schools--I
    just checked the numbers--Mississippi is going to get an
    additional $46 million to help those children in poor
    communities--rural, urban, whatever it might be--who have been
    in historically very low-performing schools to try and
    transform the opportunities for them.
        So, it is a huge influx of resources coming to Mississippi
    and coming to every State around the country. And what I think
    we have done, quite frankly, is we have labeled lots of schools
    failures, but not much has changed in most places. In most
    places we really haven't seen the kind of transformational
    change to help those poor students break out of poverty and
    build successful lives.
        We are putting out an unprecedented amount of money--it is
    interesting that Race to the Top has gotten all the press and
    publicity. That is for 100 percent of the Race to the Top
    schools. That is $4 billion. But, there is $3.5 billion in
    school improvement grant funds just for the bottom 5 percent.
        And so, almost $46 million comes to Mississippi. The State
    is going to figure out what is the best way to turn around
    those low-performing schools. We have a couple of models out
    there. But we want to make sure those children who historically
    have been underserved have a chance with a real sense of
    urgency to get a much better education.

                   RURAL EDUCATION ACHIEVEMENT PROGRAM (REAP)

        Senator Cochran. Well, one thing that bothers me, too, is
    the fact that we have level funding proposed by the
    administration for the REAP. The budget request freezes that
    program at a level of $174.9 million. It was designed to help
    rural districts overcome the additional costs associated with
    geographic isolation, distances that have to be traveled during
    the day in school buses from rural areas to the places where
    the schools are located.
        Transportation costs are up. Employee benefit costs are
    down. And there is an increase in poverty in most of these
    areas that qualify for the REAP, but it is level funding. That
    is an example of something that disturbs me, and I hope the
    administration will look carefully at the decisions that are
    made by the congressional committees in the House and the
    Senate.
        I would not be surprised at all, and as a matter of fact, I
    am hopeful that we will increase these funds that are available
    for competitive grants for some States and districts. But
    formula grants provide a reliable stream of funding to States
    and local districts that just don't have the teachers or the
    administrators with the educational backgrounds that are
    required to help move these districts forward.

                           MIGRANT EDUCATION PROGRAM

        So I know that money is tight. The Migrant Education
    Program is another one. Mississippi's funds for that program
    are going to be reduced from $1.076 million to $640,000. And
    these things just keep cropping up in this budget request page
    after page after page.

                                 CONSOLIDATIONS

        Consolidating programs, as the administration proposes in
    the Even Start Family Literacy program, is going to cost
    Mississippi an estimated $830,000 in Even Start funding for
    fiscal year 2010. So I hope the administration will take
    another look at the budget request and work with the Congress
    to try to identify a fairer and more acceptable program for
    rural schools and small States.

                          INVESTING IN INNOVATION FUND

        Secretary Duncan. I absolutely look forward to working with
    you, Senator. And just to reiterate, the things we are doing,
    like the Investing in Innovation Fund, that $650 million fund,
    have actually included a competitive advantage for rural
    communities and rural districts. So we are really trying to
    make sure we are touching those communities.

                             PROGRAM CONSOLIDATIONS

        Where we consolidated programs, in every area, we actually
    increased funding. So there is a chance, whether it is around
    teachers and leaders, whether it is around a well-rounded
    education, student supports, diverse learners, because in every
    area we consolidated, we are actually increasing the amount of
    funds, which doesn't usually happen with consolidation. So
    there is a real chance for States and districts to put their
    best foot forward and get more resources in those areas. But we
    are trying to do fewer things, but do those things, those fewer
    things, do them in a world-class manner.
        Senator Harkin. Thank you, Senator Cochran.
        Senator Landrieu.

                    RACE TO THE TOP--FIRST ROUND COMPETITION

        Senator Landrieu. Thank you.
        Thank you, Mr. Secretary. And I appreciate your enthusiasm
    and your focus on improving our schools because it is quite a
    challenge.
        I wanted to ask you, if I could, just about the Race to the
    Top program. Let me just get to my question here. We were one
    of the States that applied, as you know, and have been very
    encouraged by words that you and your administration have
    spoken about the good work that is happening in Louisiana that
    has been going on, as you know, for some time.
        The administration requested $1.4 billion to extend Race to
    the Top. Now the first competition has come to a close. We were
    not one of the States chosen, but I believe Delaware and, what
    was the other one, were.
        After evaluating some of the scores, however, of the States
    that did apply, it was interesting that if you decided to grade
    them somewhat differently by throwing out the high and the low,
    which is done in the Olympics and is done in many competitions,
    to get a better, clear average, the top two States would have
    remained the same. But in Louisiana's case, we would have moved
    up considerably.

                      RACE TO THE TOP--APPLICATION SCORING

        So that is just one question I pose to you. When you do the
    second round, are you thinking about the opportunity of a more
    fair scoring, number one? And number two, it was also
    interesting that a high weight was given to what seemed to be
    an application that had all parishes or counties onboard, all
    teacher unions onboard, all school boards onboard, which, in an
    ideal world, you know, would be what we were hoping for.
        But as you know, as a reformer in the trenches, it is
    sometimes difficult to deliver all the teacher unions, all the
    counties, all the parishes. And for applications like ours that
    represented a very strong and risk associated application for
    about half, to not be designated, I have to say, was just a
    real disappointment.
        So my questions are, one, is there going to be any new
    approach to scoring that might result in a more fair reflection
    of the actual quality of the application? And number two, why
    are we going to insist that if you can't get every school board
    and every county stepped up, your State can't try with the
    counties that are ready to go and willing to take the risk?
        Secretary Duncan. Really good questions, and obviously,
    Louisiana has done an extraordinary job in very, very difficult
    circumstances of driving reform and has made huge progress, and
    I know there is real disappointment that the State didn't win
    in the first round. I would absolutely urge the State to come
    back and come back stronger the second round. As you know,
    there is a huge amount of money that is going to go out,
    between $3.4 billion and $3.5 billion in the second go-around.
        To answer those two questions, I will answer the second
    question first that bold reform and broad stakeholder support
    is a winning combination. But watered down reform and broad
    stakeholder support is not. Bold reform matters, and I----
        Senator Landrieu. But let me just interrupt because this is
    very important. Nothing in our application was watered down.
        Secretary Duncan. Right.
        Senator Landrieu. The problem is if you push to get
    everyone there, you will give us no choice but to water down.
    In other words, half of something strong is better than 100
    percent of something weak and watered down. And that is what I
    am very concerned about, and I think there are many members
    that are driving this reform effort that are absolutely taken
    aback at the posture of this department.
        Secretary Duncan. Well, again, if you look at the results,
    the two winners were able to do both. But if you look at folks
    that came in with high scores right behind that, they had very
    broad reforms. And if we are going to fund 10 to 15 States,
    whatever the magic number will be in the second round, I think
    there is a huge opportunity there. So I----
        Senator Landrieu. So it is a real opportunity, I want to
    just say, for some unions. And some unions have been
    supportive, and some teacher unions have been supportive. But
    it is a real opportunity for those that don't want to be
    supportive, and there are obviously many entrenched interests,
    not just some unions, but school board members and others. I
    mean, this is a fight in every State, as anybody that is in
    this battle knows. This is a battle. It is not a waltz.
        And so, what you are saying is if you can't get everyone in
    your State to step up, we can't help you to start because it is
    so counter to the way that I have been leading this reform
    movement in Louisiana. So I just want to, Mr. Chairman, say how
    strongly I feel about the way this administration--and I am one
    of their biggest supporters. But this is going to have to be
    changed, in my view. Not watering down, but strengthening and
    rewarding those that will take the risk of reform, whether
    everybody is there or not.
        In any efforts I have led for reform, you don't get 100
    percent participation at the front end. You might get 10 people
    that show up at the line and say we are willing to go. Ninety
    people are back here. Then next year, 20 percent show up at the
    line, and you leave 80 percent behind. And soon, it is reform.
    So I am completely confused.

                            TEACH FOR AMERICA (TFA)

        And my second question is this, and I will add, Mr.
    Chairman, I know. But TFA, and the members of this subcommittee
    understand how strong TFA has been. I want to just read for the
    record, Mr. Chairman, it is harder today to get into Harvard
    Law School--I mean, it is harder today to get into TFA than it
    is to get into Harvard Law School. What a phenomenal success
    TFA has been.
        Think about that. Not even a Government-run program, not
    even a Government-started program. But a nonprofit,
    entrepreneurial, innovative program that has accomplished more
    than all of us, in my view, together, getting qualified
    teachers in the classroom, and we haven't fully funded their
    effort. I am going to submit a full funding to this chairman
    for his request.
        And when any Federal program can say that they are putting
    more qualified teachers in the classroom than are going to
    Harvard Law School, then we might take the funding and shift it
    over there.
        Thank you.
        Senator Harkin. Thank you, Senator.
        Senator Alexander.

                        FUNDING EXCELLENCE IN EDUCATION

        Senator Alexander. Thank you, Mr. Chairman.
        Mr. Secretary, thank you for being here.
        I very much appreciate your leadership, the way you go
    about your job, the bipartisan way you do it. I am glad to be a
    part of a bipartisan working group to try to fix No Child Left
    Behind. I appreciate the struggle of trying to emphasize
    excellence at the same time you are trying to support schools,
    both.
        I remember as a Governor when I tried to encourage master
    teachers and centers of excellence and chairs of excellence.
    People would say, well, why would you do that when we need
    money for what we are already doing? And the answer really was,
    I don't think taxpayers really want to support much more
    funding for more of the same, but they will support a lot more
    funding for excellence. And there are many different ways to do
    it, but I am going to support your request for funding for
    excellence wherever I have the opportunity to do it.

                    RACE TO THE TOP--FIRST ROUND COMPETITION

        And I have a question along a couple of lines about three
    specific programs, but I wanted, in senatorial custom, to make
    a couple of preliminary observations first. One is Tennessee
    was glad--and I can say this because I had nothing to do with
    it. The Governor, the legislature, the educators did it--to be
    one of the two winners of Race to the Top.
        And as terrific as that is going to be for the State, the
    Federal Government is really giving with one hand and taking
    away with another because the new healthcare bill, between 2014
    and 2019, is going to add between $1.1 billion and $1.5 billion
    of costs, most of which will have to come out of education,
    while the Race to the Top brings half a billion dollars of
    costs.

                                  ARRA FUNDING

        Second, our Governor, a Democratic Governor, said at the
    time of the stimulus funding 2 years ago that these are one-
    time funds, don't spend it on continuing operations. So as the
    chairman talks about $23 billion more, I wonder from whose
    schoolchildren we are going to borrow this money? Because we
    have a looming debt crisis in our country, and we will need to
    debate this. We all want to help our children, help our
    schools. But that is a deep concern.

                      FEDERAL DIRECT STUDENT LOANS PROGRAM

        As far as student loans, we didn't have much of a chance to
    debate that here. You know my views, and they are different
    than yours. But I think it is important to say that what we are
    really doing with this Federal takeover of the student loan
    program is borrowing money from 19 million students. We are
    borrowing the money--the Federal Government is--at 2.8 percent
    and loaning it to them at 6.8 percent and taking the savings
    and using it to pay for Pell Grants and some for healthcare.
        And I think it would be better if we are going to take it
    over and create so-called ``savings'' if we give the students
    the savings. We could lower the interest rate from 6.8 percent
    to 5.3 percent on the student loans and let that $61 billion or
    so be in the pockets of the 19 million students who are
    borrowing money to go to school.

                          HISTORY AND CIVICS EDUCATION

        Now on my questions, and then I will leave the rest of my
    time to you, there are three programs that I am especially
    interested in. One is the proposal Senator Byrd, the late
    Senator Kennedy, and I introduced to try to take the Federal
    programs on history and civics and consolidate them and make
    them an appropriate part of what the Federal Government does to
    help children learn--to support State and local efforts to help
    children learn what it means to be an American and finding a
    dedicated stream of funding for that.

                          TEACHER INCENTIVE FUND (TIF)

        Two is the TIF, which has been the most useful tool, I
    think, to you in Chicago, when you were superintendent, to many
    school districts around the country to help find effective
    ways, fair ways to pay teachers more for teaching well. And I
    wonder under your blueprint plans whether you are not running
    the risk of de-emphasizing that program?

                                      TFA

        And finally, along with Senator Landrieu, I strongly
    support TFA. It is an authorized program in the law, not an
    earmark, just as the history program is. And I am wondering if
    your blueprint that you are working with us on fixing No Child
    Left Behind doesn't de-emphasize it as well?
        So history and civics, the TIF for effective teaching and
    school leadership, and TFA, your comments on the priority those
    will have as you look forward the next few years?
        Secretary Duncan. Yes. I will try and take them in reverse
    order. On TFA, and I appreciate your passion and leadership on
    that, and Senator Landrieu, your passion and leadership. And
    let me be very clear, I am a huge fan of TFA, and I have seen
    the benefits around the country. I actually helped bring them
    to Chicago before I was the CEO of Chicago Public Schools. And
    that influx of talent, commitment, and passion has been
    extraordinary around the country.
        Senator Landrieu, as you know so well, talent matters
    tremendously. It is a phenomenal pool of hard-working,
    committed folks going to tough communities--inner-city, urban,
    rural, whatever it might be--who want to make a difference in
    students' lives. And so, I just want to be very, very clear
    where I stand on that.
        And the funding, we have, as you know, dramatically
    increased that pool of funding for teacher programs, and there
    is a real chance for TFA to put their best foot forward and
    through a competitive process bring in not just what they
    currently get but, frankly, significantly more resources. And
    that potential is there for them, as there are for other great
    programs that are bringing talent into education.
        And I don't think there is anything more important we can
    do as the baby boomer generation moves toward retirement than
    to bring in great new talent.
        Following the submission of their application for funding,
    the Department will likely award a grant to TFA in June 2010.
    Grant funds are typically available for 12 months, which would
    be until June 2011. And so, there should be funding there, and
    there will also be an opportunity going forward for them to
    compete for, frankly, significantly larger pools of money.

                                 TIF INVESTMENT

        On the TIF, I have appreciated your leadership and vision
    on this for a long time. And it is one of the most important
    things we think we can do. As you know, we want to
    significantly increase that investment, going from $400 million
    in fiscal year 2010 to a proposed $950 million in 2011.
        And please, don't have any concerns about watering that
    down. We will absolutely--let me be clear. We will absolutely
    require grantees to create systems for identifying and
    rewarding outstanding teachers, as well as principals. And so,
    that commitment is unwavering, and I can't be more clear on
    that.
        On the first one, teaching American history, again, that is
    an area where we are actually increasing the investment, $265
    million for the history, arts, financial literacy, foreign
    languages, a 17 percent increase. We are doing it, as you know,
    on a competitive basis. But that pool of money, again, did not
    shrink, it is up 17 percent, and great programs have a chance,
    again, not just to maintain funding, but to, frankly, increase
    their funding.
        Senator Alexander. Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator Alexander.
        Senator Pryor.

                COMPETITIVE ABILITY OF RURAL AND SMALL DISTRICTS

        Senator Pryor. Thank you, Mr. Chairman.
        And Mr. Secretary, thank you for being here today, and I do
    have a few questions for you. And first, let me say that I like
    competition. I think that is good that we introduce more
    competition into some of this. But I do have a concern about a
    rural State or a rural setting, smaller school districts that
    maybe don't have the resources and maybe don't have the grant
    writing background.
        And how do you factor that in considering that some
    districts in some States--some of the areas that need it the
    most--may be the least capable of going through the process?
    How do you address that?
        Secretary Duncan. That is a great question. We spent a lot
    of time thinking about that. And let me be really clear. We are
    not looking for great grant writers or fancy PowerPoint
    presentations. That is not our interest.
        We want to go where the need is. And there is tremendous
    unmet need in rural communities. And what we want people to do
    is just to simply show us their vision, show us where they want
    to go, show us their commitment to raising the bar for all
    students and closing the achievement gap, and that is where we
    want to invest.
        And so, whether it is the TIF grants, whether it is
    Investing in Innovation, where we made actually a competitive
    advantage for rural communities, we want the funds to go where
    the need is. And so, hold us accountable for that, but this is
    not going to be judged by the prettiest pie chart or the
    prettiest PowerPoint presentation. We want to go where there is
    real commitment, where there is real courage, where folks want
    to get better and demonstrate that commitment. And we want to
    partner with you to take to scale what works.

                   NUMBER OF URBAN VS. RURAL SCHOOL DISTRICTS

        If we are serious about scaling-up best practices, the
    majority of our students are not in urban school districts.
    That is the reality. It is 2,000 districts out of 15,000. We
    have to play on a nationwide basis, and we are absolutely
    committed to doing that.

                     COMPARABILITY OF EDUCATIONAL SERVICES

        Senator Pryor. Great. Let me ask you another question about
    comparability. About 57 percent of all students in Arkansas are
    economically disadvantaged, and more than 1,700 students in my
    State take advantage of supplemental services. In terms of
    comparability, your blueprint aims to ``encourage increased
    resource equity at every level of the system'' and to ``over
    time require districts to ensure that their high-poverty
    schools receive State and local funding levels comparable to
    those received by their low-poverty schools.''
        Can you clarify that and explain how that works and what
    you mean by that?

                ADDRESSING THE ACHIEVEMENT AND OPPORTUNITY GAPS

        Secretary Duncan. Yes. Let me just, you know, explain the
    big picture. We as a Nation are rightfully focused on the
    achievement gap. I think we have had lots of talk about that.
    We have had very few places fundamentally breaking through on
    closing that achievement gap. And what I keep saying is that if
    we are serious about closing the achievement gap, we have to
    close what I call the opportunity gap.
        And to do that, we have to make sure that communities that
    have been historically underserved, be they rural, inner-city,
    urban, are finding ways to attract and retain the best teachers
    and the best principals. Talent matters tremendously in
    education.
        And I think in far too many places, there are very few
    incentives and, frankly, lots of disincentives for the best
    talent to go to the communities and the children who need the
    most help. And so, what we would really be doing is challenging
    everyone to think about what we are doing systemically to get
    students in the communities who often, frankly, for decades
    have been poorly served, how are we going to change that? How
    are we going to challenge the status quo?
        And this is one of many attempts to really start to address
    that question in a much more meaningful way than what I have
    seen historically.

                        APPROACH TO ESEA REAUTHORIZATION

        Senator Pryor. Good. You know, when I think about your
    background being from the Chicago area, and I know you have
    done a lot of work with inner-city work there, that is great.
    And then when I look at some of our districts in Arkansas that
    are rural and have all kinds of challenges, and a lot of our
    students there do--and I think if you look at a test score,
    they might score the same in some ways, but there may be a lot
    of factors that go into that score that cause them, for
    different reasons, to score that way. And I was glad to hear
    you say earlier that your three Fs are fair, flexible, and
    focused because I do think you have to be fair, but also you
    have to be flexible. You have to recognize the differences and
    the different factors that go into getting the results we want
    to get. And I remember back when I was the attorney general of
    my State, we had a big lawsuit over school funding. And some of
    that is very difficult to determine in terms of how you get
    from point A to point B and what you can do as a State or a
    district or certainly the Department of Education--what you can
    do to try to get us the results we need.
        So I just encourage you to be fair, flexible, and focused,
    but also keep in mind that second F, that flexibility, because
    one size is not going to fit all.

                            RECOGNIZING ACHIEVEMENT

        Secretary Duncan. No, I really appreciate that. And again,
    we just want to look for places that have that commitment to
    closing the gap and continue to support them.
        I just checked Arkansas's money for school turnarounds,
    again that bottom 5 percent in every State, you define who
    those bottom 5 percent are. You figure out how we get better--
    $34 million. We are trying to put a huge amount of resources
    for, again, those children who haven't had the opportunities
    they need to fundamentally break through, whether it is more
    time, whether it is different leadership. Whatever it might be,
    we have to do better with a real sense of urgency.
        And we are trying to put our money where our mouth is. We
    are trying to put our resources there and say let us have some
    courage and let us do some things in a different manner.
        The final thing I will say is that so much of what bothered
    me about the previous law, well--let me just give you a quick
    example. Let us say you were a sixth grade teacher, and I came
    to you as a student three grade levels behind, reading at a
    third grade level. If I left your classroom one grade level
    behind, you were labeled a failure. Your school was labeled a
    failure.
        I think not only are you not a failure, I don't just think
    you are a good teacher, I think you are a great teacher. I
    gained 2 years of growth for a year's instruction. That teacher
    is a phenomenal teacher. We should be learning from them. We
    shouldn't be stigmatizing them. We should be replicating that.
    We should be rewarding that.
        We should figure out why I came to your class three grade
    levels behind and figure out what is going on downstream.
        Senator Pryor. Right.
        Secretary Duncan. But we want to really look at growth and
    gain and how much we are improving. If a dropout rate is going
    from 50 percent to 45 to 40 to 35, it's still too high, but
    it's going the right way. If it is at 50, 50, 50, 52, 55, well,
    that is a real problem. That is a place that is stagnating, not
    getting any better.

                        PROMISE NEIGHBORHOODS INITIATIVE

        So really looking at improvement, and it takes lots of
    things. It takes a community. It takes parental engagement. It
    takes challenging students. We have this Promise Neighborhoods
    Initiative, which we haven't talked about, where we want to
    create communities around schools that make sure students are
    safe and make sure the entire neighborhood is working behind
    students so they can be successful academically.
        So we want to come at this from a lot of different
    approaches, but ultimately, we want to look at who is serious
    about seeing students improve dramatically.
        Senator Pryor. Yes. I think my State has a good story to
    tell there. The numbers in my State are going in the right
    direction, but it has taken a lot of hard work at the local and
    State level.
        Thank you, Mr. Chairman.
        Senator Harkin. Thank you, Senator.
        Senator Shelby.

                      IMPACT OF WEAK ECONOMY ON EDUCATION

        Senator Shelby. Thank you, Mr. Chairman.
        Welcome, Mr. Secretary. I want to get into an area that
    Senator Pryor did. My State of Alabama, the unemployment rate
    in Alabama, February 2007, was 3.4 percent. We had some good
    years, a lot of good years.
        The unemployment rate jumped to 4.2 percent February 2008.
    February 2009, it had gone up to 8.7 percent. February 2010, it
    is 11.1 percent, it was. So this wreaks havoc on everything--
    the economy, the collection of taxes, the schools.
        I think we have been making a lot of progress in my State
    of Alabama with our schools, but the economy is weakened, as I
    have pointed out. We have lost more than 2,000 teachers. Think
    about it. Two thousand teachers in the past 4 years, and our
    jobless rate, as I pointed out, has tripled. There is a
    correlation between all this.
        It has been proposed that we might lose another 1,500
    teachers in the coming years. How will schools, not just my
    State, but around the country, but particularly Alabama right
    now, if we continue to carry out reforms, can we do this as we
    lose all these teachers, Mr. Secretary?

                       EMERGENCY JOBS BILL FOR EDUCATION

        Secretary Duncan. It is a great question. Before you got
    here, the Chairman spoke eloquently, and I supported him. I
    think we need--I don't know if you would agree or disagree. I
    think we need an emergency jobs bill. I don't have my numbers
    in front of me for Alabama. But we saved, conservatively,
    300,000 educator jobs around the country last year.
        Alabama got absolutely its fair share, but we are very,
    very concerned. So I am strongly supporting emergency action by
    Congress. What is happening in Alabama, we are seeing very,
    very similar, if not worse numbers in the majority of States
    around the country. It is a devastating time.
        Senator Shelby. It is not just my State, but we have
    problems in my State. We have a lot of promise, but we have
    some problems, as you know. But it is the Nation----
        Secretary Duncan. It is the entire country. No one is
    untouched by this. And when you see tens of thousands, hundreds
    of thousands of educators being laid off, that has a huge
    impact on the entire economy. It has an impact on students'
    futures, and I think this would be the right investment to
    make. It is the right thing to do at the right time for the
    right reasons.
        So that is something that Senator Harkin is actually
    proposing today, an emergency jobs bill, and we want to work
    with him on the details. But, if it is something interesting, I
    would love to continue that conversation.

                 RURAL DISTRICTS ABILITY TO COMPETE FOR GRANTS

        Senator Shelby. But the grants, Senator Pryor brought this
    up, does the grant program do detriment to a lot of the rural
    counties, smaller counties all over America, as opposed to some
    of the more urbane, urban counties?
        Secretary Duncan. Not at all. And again, I want you to
    really hold us accountable. What we want is to invest--the
    Investing in Innovation Fund or the Promise Neighborhoods
    initiative, we want to work throughout the country. And there
    is tremendous unmet need in rural communities and rural States.
        I was fortunate to be in your State a couple of weeks back
    and have an absolutely memorable visit, and the challenges that
    I saw were staggering. And we want to invest in those places
    that want to get better and where there is tremendous need, and
    that includes rural communities.
        Senator Shelby. Just a few minutes ago, I believe, you
    stated, and I will quote you, ``We want to go where the need
    is.''
        Secretary Duncan. Yes, sir.

                          HIGH SCHOOL GRADUATION RATE

        Senator Shelby. Just a few minutes ago. Well, obviously, we
    have some needs. We are not by ourselves. Alabama has, it is my
    information, had a high school graduation rate of 67 percent,
    compared to the national rate of 74 percent. And this is--
    although we have improved, we have got a long way to go.
        But if we lose money or we lose out on the funding program,
    I think we will not be by ourselves, would we?
        Secretary Duncan. No, I agree. And so, again, I think if we
    can get a jobs bill passed, that would be a huge benefit.
    Alabama has made real progress. I am a big fan of your State
    superintendent. I think he is doing----
        Senator Shelby. He is going to testify in a few minutes.
        Secretary Duncan. Is he? Well, he is a fantastic--I am glad
    I said the right thing then.
        But in all seriousness, I am a big fan of his. He is
    working extraordinarily hard. To see his level of commitment
    and the community support of his efforts was remarkable, and I
    think with the jobs--he will talk about the problems, but with
    a jobs bill we have a chance to make sure we don't get worse
    and, at the same time, try and push for the kind of real
    transformational change we need.
        Senator Shelby. Well, in a nutshell, how will the grant
    program work as compared to the status quo?
        Secretary Duncan. Well, we are talking about a couple of
    different things. If we have a jobs program, that would help to
    preserve somewhere between 100,000 and 300,000 jobs, education
    jobs around the country. And there is desperate need out there.
    At the same time we are doing that, we don't just want to
    preserve the status quo. We have to continue to get better.
        And so, Race to the Top, the Investing in Innovation Fund,
    School Improvement Grants, TIF, Promise Neighborhoods, all
    those are attempts to really have the kind of breakthrough
    changes that we need. So we need to do both at the same time.
    These ideas are not in conflict. We have got to do both.
        Senator Shelby. But if you go where the need is, you are
    going to go to a lot of the rural areas, too, are you not?
        Secretary Duncan. Yes, sir.
        Senator Shelby. Okay. Thank you, Mr. Chairman.

                 CLOSING REMARKS TO THE SECRETARY OF EDUCATION

        Senator Harkin. Secretary Duncan, thank you very much for
    your testimony and for answering questions. We may hold the
    record open for a while here to have some written questions
    from Senators who were not able to be here because of schedule
    conflicts.
        So, with that, Mr. Secretary, thank you very much. Look
    forward to working with you.
        Secretary Duncan. Thanks for all your leadership.
        Senator Harkin. Thank you, Mr. Secretary.

                      INTRODUCTION OF EDUCATION JOBS PANEL

        The Secretary will be excused. We have a second panel that
    will be coming up, a panel to talk about education jobs, which
    we heard about here with Secretary Duncan and others on this
    panel.
        Senator Harkin. All right. If we could get our panel
    seated? Mr. Ramon C. Cortines is the superintendent of the Los
    Angeles Unified School District. Mr. Cortines began his
    teaching career in Aptos, California, in 1956. From 1995 to
    1997, he served as special adviser to U.S. Secretary of
    Education Richard Riley.
        We have Chris Bern, president of the Iowa State Education
    Association and a math teacher at Knoxville High School,
    graduate of Buena Vista College in Storm Lake with a degree in
    mathematics.
        And I will skip over the next because I will leave that to
    Senator Shelby. Then we have Mr. Marc S. Herzog, currently
    chancellor of Connecticut Community Colleges, a position he has
    held since 1999. Mr. Herzog holds a master's of science degree
    in guidance and counseling from Central Connecticut State
    University and a bachelor of arts degree in education from
    Yankton College in South Dakota.
        And with that, I will yield to my friend from Alabama for
    purposes of an introduction.
        Senator Shelby. Thank you. Thank you, Chairman Harkin.
        I will be brief, but I don't get this chance every day. We
    have a distinguished superintendent of education from Alabama.
    He is sitting here, Dr. Joe Morton, and I am pleased to welcome
    him here, and I hope to engage him in a few minutes in some
    questions.
        Dr. Morton's impressive background includes, among other
    things, the creation and implementation of the Alabama Reading
    Initiative; the Alabama Math, Science, and Technology
    Initiative; and the First Choice plan, a new graduation plan
    for Alabama students. We are proud of his tenure. Under his
    tenure, we have shown significant academic gains in reading and
    math assessment scores, and he has been judged a national
    leader in training future teachers and principals.
        We are pleased to have you here today, Dr. Morton.
        Senator Harkin. Thank you very much, Senator Shelby.
        Dr. Morton, we welcome you here also.
        We will start here from just as I introduced, Dr. Cortines
    over. And I looked over your testimonies last evening. They
    will all be made a part of the record in their entirety, and I
    would ask if you could kind of sum it up in, oh, 5 to 7
    minutes, and then we can get into some questions and answers.
        I have asked this panel to be here to mostly focus on the
    issue of jobs and what is happening. You heard us talk here
    before with the Secretary. Senator Shelby talked about it also.
    What are we seeing out there? What is happening so that we are
    not caught unawares here? What are we looking at next year in
    your States, in your districts, things like that, that we
    should be taking some action on very soon.
        If you have other things you want to talk about, that is
    fine, too. But I would like to focus a little bit on this jobs
    issue.
        Mr. Cortines, welcome again. Here we just had someone from
    Los Angeles at a hearing yesterday, Green Dot.
        Mr. Cortines. Marco Petruzzi.
        Senator Harkin. Exactly, right. He was on another Committee
    I chaired yesterday.
        Mr. Cortines, welcome, and please proceed.

    STATEMENT OF RAMON C. CORTINES, SUPERINTENDENT, LOS
                ANGELES UNIFIED SCHOOL DISTRICT
        Mr. Cortines. Thank you.
        Chairman Harkin and subcommittee members, thank you for
    this invitation. I head the second-largest district in the
    Nation. Our enrollment is 618,000 students, and as you know, it
    is larger than the total number of students who attend public
    schools in 25 States.
        First, let me thank and congratulate Senator Harkin for
    introducing the Keep Our Educators Working, which would create
    a $23 billion education jobs fund modeled after the SFSF that
    was established in the ARRA. I support this bill and ask all to
    support for the teachers, the principals, the counselors,
    school nurses, and other essential public school employees that
    are losing their jobs.
        Today, I ask you to help us to stop the hemorrhaging of
    teachers and other essential public school employees in Los
    Angeles and across the Nation in other big cities, in small
    towns, and in rural areas. Two thousand teachers gone from our
    district, and more are on the chopping block right now as State
    funding continues to shrink.
        I don't know every name of those 2,000 teachers, but our
    students do. Who is the first person you see at a school?
    Office workers, who are disappearing. Our schools would neither
    be healthy or beautiful without custodians, whose numbers
    continue to dwindle.
        You name it--teachers, principals, counselors, school
    nurses, cafeteria workers, support personnel--are a part of an
    unchecked exodus forced by California's financial realities.
        Unfortunately, it is not over. The district was forced last
    month to send out nearly 5,200 reduction in force notices to
    principals, teachers, and other school-based staff. Some,
    though certainly not all, will keep their jobs because the
    unions representing these individuals have agreed last week to
    shorten the school year by 5 days this June and next year, too,
    to save $175 million.
        As a result, our students' teachers are losing
    instructional time and taking a pay cut. Their sacrifices are
    generally appreciated, but much more is needed to close a $640
    million budget gap. Because of the State budget problems,
    thousands of noninstructional employees will soon lose their
    jobs. Many of those lucky enough to keep their positions are
    subject to unpaid furlough days, a steep reduction of work
    time, and significant pay cuts during the next school year.
        Furlough days are one way to save jobs. I have worked with
    the unions representing school police, office workers, bus
    drivers, and others who are willing to work fewer days and earn
    less so more employees can keep their jobs. That is why I am
    asking to save our employees and protect the futures of our
    students.
        I am asking to support the $23 billion in education aid
    that Members of the House included through the SFSF in the Jobs
    for Main Street Act. If Congress provides this money, the Los
    Angeles District could receive approximately $250 million and
    save as many as 3,000 jobs.
        What more can Washington do? Provide more funding for the
    disadvantaged students. And it has been said this morning,
    whether they are in urban districts or mid-sized districts or
    rural America, President Obama's budget for the fiscal year
    2010-2011 freezes title I spending, and that will have a very
    negative consequence for our district. Devastating to the
    district's 631 title I schools, it will specifically hurt at
    least 78 percent of our students based on eligibility for free
    and reduced lunch periods and hamper our efforts to close the
    achievement gap.
        We appreciate the additional title I dollars received last
    year. Neither I nor headquarters dictated how that money would
    be spent. It was pushed out to the schools, and school
    teachers, parents, administrators, and the community, they made
    the decisions on how we would spend that money. For example,
    many schools chose to hire additional teachers to preserve
    smaller class size at the primary grades.
        Washington can also help keep a promise made long ago to
    provide 40 percent of the cost of special education. The fiscal
    year 2010-2011 budget would limit funding to 17 percent,
    resulting in a shortage of $172 million for the district. And
    despite the shortfall, the Federal Government requires special
    education to get the services, and they deserve to support them
    in every way.
        Paying for these requirements diverts local contributions
    from the instruction of more than 500,000 students who do not
    have disabilities.
        Senator Harkin. Mr. Cortines, could I ask you to summarize,
    please?

                               PREPARED STATEMENT

        Mr. Cortines. Okay. As I conclude, I want you to know that
    one of our outstanding seniors, Tyki, read--if you read his
    bio, you may dismiss him as an unfortunate statistic. Born
    crack addicted, father passed away, mother incarcerated,
    bounced from home to home.
        Today, Tyki is a straight-A student at Washington Prep High
    School in south Los Angeles. He is excelling in advanced
    placement calculus, biology, chemistry, and physics. And when
    he graduates, he is headed to the U.S. Military Academy. There
    are countless stories like Tyki in the L.A. student body.
        Thank you for your consideration, support, and help.
        [The statement follows:]

                    Prepared Statement of Ramon C. Cortines

        Chairman Harkin and subcommittee members, thank you for this
    invitation to testify on behalf of the Los Angeles Unified School
    District (LAUSD), the Nation's second largest. I am Superintendent
    Ramon C. Cortines. Our enrollment of 618,000 students is larger than
    the total number of students who attend public school in 25 States. I
    also would like to take this opportunity to thank Chairman Harkin for
    his strong leadership and advocacy for education issues in the
    Congress. We stand together in the march toward an educated America,
    where all students are prepared and encouraged to read, write, think,
    and speak as 21st century learners who will become the next generation
    of leaders, teachers, doctors, engineers, writers, electricians,
    contractors, and business owners. That will not happen if our district
    and school districts across the Nation in big cities, small towns and
    rural areas continue to hemorrhage teachers and other essential
    employees.

                          CALIFORNIA'S BAD NEWS BUDGET

        In California, public education is suffering one of the greatest
    threats in decades as funding from the State shrinks. Also threatened
    is an opportunity for great, systemic and long-lasting reform, always a
    challenge but even more so when the unpredictable budget cuts keep
    coming, month after month.
        The numerous and unyielding reductions in State funding have
    translated into the LAUSD's current deficit of $640 million and a
    projected deficit of $263 million in 2011-2012. And, the news never
    improves. State Controller John Chiang recently announced that the
    upcoming fiscal years will be particularly difficult for our State
    because the temporary tax hikes approved by the legislature last year
    will expire; Federal stimulus funds will be gone; and funds that the
    State borrowed from local governments will become due. Furthermore, the
    State's Legislative Analyst Office has projected that California will
    have a $20 billion deficit every year for the next 5 years.
        It is not hyperbole to State that the LAUSD is again facing a
    budget crisis of the most unprecedented proportion. We have cut $1.5
    billion from our budgets over the past 2 years. That's a lot of jobs.
        Two thousand teachers gone last year and more are on the chopping
    block right now. Office workers, the first person you see at a school,
    disappearing. Our schools would be neither healthy nor beautiful
    without custodians whose numbers continue to dwindle. You name it.
    Teachers, administrators, counselors, school nurses, cafeteria workers,
    support personnel are part of an exodus forced by financial realities.
        LAUSD was forced last month to send out nearly 5,200 reduction-in-
    force notices to teachers, principals, and other school-based staff.
    Some, though certainly not all, will keep their jobs because the unions
    representing our teachers and administrators just agreed last week to
    shorten the school year by 5 days this June and next in order to save
    about $157 million and preserve class sizes that are already too high.
    Teachers are losing instructional time and taking a pay cut. Their
    sacrifices are certainly appreciated, but alone do not close the budget
    gap.
        Unfortunately, many more LAUSD employees will soon lose their jobs
    including thousands of noninstructional staff. Many of the lucky ones
    who keep their jobs must take more than 40 unpaid furlough days, a pay
    cut of more than 20 percent as the workload increases. I have worked
    with unions representing school police, office workers, bus drivers and
    others who are willing to work fewer days, and earn less so more can
    keep their jobs.

                    WHAT WASHINGTON CAN DO--JOBS, JOBS, JOBS

        LAUSD is not the only district in California facing layoffs.
    Statewide, nearly 22,000 teachers have received notices of potential
    layoffs. According to the California Department of Education, more than
    16,000 teachers lost their jobs last year, and roughly 10,000
    classified or noninstructional school employees have met the same fate
    over the last couple of budget cycles. As you can see, public schools
    urgently need additional money now for the 2010-11 school year.
        I applaud members of the House of Representatives for including an
    additional $23 billion in education aid through the State Fiscal
    Stabilization Fund (SFSF) in the Jobs for Main Street Act, which passed
    in December. I urge the Senate to support similar education jobs relief
    to save teachers and protect the futures of students. If Congress
    provides this $23 billion, it is estimated that LAUSD could receive
    approximately $250 million and save as many as 3,000 jobs.
       what more can washington do--more money for disadvantaged students
        In addition to an immediate infusion of fiscal relief to save jobs,
    Washington should provide additional investments in such critical
    education programs as title I and special education. While the fiscal
    year 2011 budget proposed by President Obama gives education an overall
    increase of $3.5 billion, including a $3 billion (12 percent) increase
    for the Elementary Secondary Education Act (ESEA), it freezes title I,
    which will have serious negative consequences for the LAUSD. It will
    hurt at least 78 percent of our students, and more as the numbers who
    qualify for free and reduced-price lunch are increasing. It will be
    devastating to LAUSD's 631 title I schools.

                          FULLY FUND SPECIAL EDUCATION

        The fiscal year 2011 budget also fails to increase the Federal
    share of funding for special education, limiting it to only 17 percent
    of the costs. Congress must make good on the original promise to
    provide 40 percent. LAUSD currently receives $135 million in Federal
    funds for special education, which--if fully funded--should amount to
    $307 million, a shortage of $172 million. During the current school
    year, LAUSD serves 82,751 special education students. The Individuals
    with Disabilities Education Act (IDEA) mandates that each special
    education student receives an individualized education plan, which
    determines required supports and services regardless of costs that
    continue to rise. Add to that financial burden, the number of special
    education students continues to rise. This unfunded Federal requirement
    forces the diversion of locally contributed general fund dollars from
    the instruction of the more than 500,000 LAUSD students who do not have
    disabilities.

       STOP THE STATE FROM HIJACKING FUNDS WASHINGTON INTENDS FOR PUBLIC
                                   EDUCATION

        We appreciate the assistance our schools have already received from
    Washington. The American Recovery and Reinvestment Act (ARRA) provided
    critical help during the current school year in the form of additional
    aid for title I of the ESEA, IDEA, and through SFSF. The funds LAUSD
    received allowed us to save approximately 7,000 jobs of teachers and
    other employees.
        With the help of $359 million from the SFSF, LAUSD was able to save
    more than 4,600 jobs last year. The ARRA title I and IDEA money helped
    us save another 2,143 jobs. In the case of the title I dollars, neither
    I nor anyone else at headquarters dictated how they would be spent.
    That money was pushed out to schools to decide how the money could be
    best spent on that individual campus.
        Even more jobs could have been saved, but unfortunately, in order
    to shore up the State's depleting resources, the California Department
    of Finance kept millions in SFSF that LAUSD had counted on to use this
    coming year to help fill our $640 million budget gap. That is certainly
    not what Washington intended. Given the State's penchant for hijacking
    dollars earmarked for public education to address its own budget
    shortfalls, those funds should flow directly to local school districts
    to protect our students, schools and jobs.

           THE UNIQUENESS OF THE LOS ANGELES UNIFIED SCHOOL DISTRICT

        As head of LAUSD, I lead the Nation's second largest district. At
    least 78 percent of our students qualify for either free or reduced-
    priced lunches. More than 74 percent of our students are Latino, and
    almost 11 percent are African American. More than 40 percent are
    English language learners, a reflection of the close to 100 languages
    and dialects spoken in their homes. LAUSD is the second largest
    employer in Los Angeles County, with 72,000 employees who serve more
    than 891 K-12 schools. Our students come from a 710-square mile area
    that, in addition to Los Angeles, includes dozens of cities and
    unincorporated neighborhoods located in the surrounding Los Angeles
    County. In short-- our size, our diversity, our mission, and our
    challenges are great.

                                   INNOVATION

        In September, 37 schools--including some brand-new campuses and
    some of our existing lowest-performing schools--will be operated by
    nonprofit groups, collaborative teams of teachers and administrators,
    and charter schools under the new and competitive Public School Choice
    Initiative. Speaking of charters schools, no district in this Nation
    has more than LAUSD. Add to these multiple routes to success for our
    students, partnership and pilot schools. If outsiders can do a better
    job of educating any of our students, we welcome their help, and we
    want to learn from their successes. If insiders can do a better job,
    including teams from the teachers' union and the bargaining unit
    representing principals and administrators, they are also welcome to
    help improve our schools.
        We also welcome the involvement of more parents. An annual school
    report card intended for parents and guardians chronicles strengths and
    weaknesses of each campus ranging from academic achievement to
    attendance, while also tracking failures and soaring improvement in
    categories such as parental involvement per school.

                       NOT SATISFIED WITH CHRONIC FAILURE

        To address the specific needs of a low-performing school, I ordered
    the turnaround of one high school under the No Child Left Behind Act. A
    new principal is already on-board and teachers, including veterans and
    newcomers, are applying for the opportunity to boost student
    achievement. That is just the beginning.
        At Belmont High School, teachers, students, and the community
    overcame decades of struggle and overcrowded classrooms to raise its
    State standardized Academic Performance Index (API) score by 78 points
    last year. Belmont High is part of the Belmont Zone of Choice where all
    area students select between the historic campus and three newly built
    high schools where students are educated through small learning
    communities and pilot schools focused on various careers and themes.

                                    PROGRESS

        LAUSD employs more than 30,000 teachers ranging from miracle
    workers and outstanding instructors to some who are not making the
    grade. Help is provided through professional development and peer
    assistance review a collaborative program with the teachers union. In
    addition, I have toughened a flawed evaluation process that too often
    allowed all but the weakest teachers to pass probation and get tenure,
    which translates into a job for life. Principals are being held
    accountable for weeding out nonpermanent teachers who are neither a
    benefit to students nor schools. Probationary teachers who received
    ``needs improvement'' in one or more categories in their last
    evaluation are being scrutinized as are 175 permanent teachers who
    received an overall ``below standard'' evaluation. Teachers who have
    received sub par evaluations for the past 2 school years, will not get
    a third chance. As a result, in June, more ineffective permanent and
    probationary teachers will be ushered out of this District--so better
    teachers will not be laid off.

                                   CONCLUSION

        Clearly the LAUSD needs your help. Please make public education
    your highest priority and fund this historic opportunity for reform.
    Teacher and other school-related jobs should be viewed as an investment
    in America's present and future. Every job lost adds to the
    unemployment rate and the housing foreclosure crisis--but in this case,
    it also hinders the education of hundreds of thousands of students in
    the Los Angeles area and across the Nation. Education-related jobs
    directly impact our students' futures in ways that can only be
    partially quantified at this time. The loss of instructional days,
    class offerings, enrichment courses, Arts programming, and other vital
    services may negatively affect our students for generations.
        Again, I would like to thank Senator Harkin for the opportunity to
    testify today, and for his strong and continuing leadership for
    education.

        Senator Harkin. Thank you very much, Mr. Cortines.
        Mr. Bern, welcome.

    STATEMENT OF CHRIS BERN, PRESIDENT, IOWA STATE
                EDUCATION ASSOCIATION
        Mr. Bern. Thank you, Chairman Harkin, Ranking Member
    Cochran, and members of the subcommittee.
        My name is Chris Bern, and I have been a public school
    teacher in Iowa for more than 30 years. Two years ago, I was
    elected to serve as president of the Iowa State Education
    Association, representing 34,000 dedicated educators in more
    than 350 school districts across Iowa.
        We are fortunate in Iowa to have some of the best public
    schools in the country. Yet today, in Iowa and across the
    country, scores of talented, experienced teachers and education
    support professionals are at risk of losing their jobs due to
    historic State and local budget deficits.
        I am very worried about what this means for our economy, as
    investments in education are inextricably linked to economic
    strength. But more importantly, I am worried about what it
    means for our students.
        A school district facing massive job losses will face
    larger class sizes and/or elimination of programs, both of
    which are detrimental to students. Not one fewer student is
    coming through our doors because of the economic crisis. They
    still need us to help them, inspire them, and educate them
    every single day.
        The education jobs crisis is not only about adults. It is
    about children, who get only one shot at an education and
    didn't ask to go to school during this crisis. Although our
    State revenue picture improved slightly this spring, we still
    anticipate as many as 1,500 teachers and support workers will
    receive pink slips. That's almost 4 percent of Iowa's education
    workforce. And that doesn't count the other positions not being
    filled due to retirements and attrition.
        The education investment in the ARRA was critically
    important. It funded 6,715 education jobs in Iowa--teachers,
    librarians, nurses, and support workers. Close to 5,000 of
    those jobs resulted directly from the aid in the SFSF. We
    desperately need this aid extended now.
        Let me tell you about one of my colleagues whose job was
    saved because of ARRA, an Iowa City special education teacher
    who was pink-slipped last year. She split her time in two
    schools working with students needing individual assistance.
    Without her, these students most certainly would fail. ARRA
    saved her job. She is now employed full time at Penn Elementary
    and continues her work with special needs students.
        What would the classroom be like without her and others
    like her? If she had lost her job, she says that she may have
    left the profession. We cannot afford that collateral damage
    either.
        The Senate needs to act quickly on an education jobs
    package. The House has already passed $23 billion for an
    education jobs fund. That bill will help save or fund as many
    as 4,900 Iowa education jobs.
        I want to thank you, Senator Harkin, for your leadership in
    introducing a similar bill in the Senate this week, the Keep
    Our Educators Working Act. I hope your colleagues will support
    it and approve it quickly.
        My colleagues back home asked me to deliver a strong
    message--please act now to help avert the looming layoffs that
    will reach into almost every Iowa community, threatening our
    economic recovery and our students' education.
        I also ask the Senate to look closely at the
    administration's proposal to increase the use of competitive
    education grants. Formula grants provide a solid foundation of
    resources needed to ensure a quality education. This has never
    been more important than in today's economy. Many rural
    districts would simply be unable to compete, as they do not
    have staff to write grant proposals. Instead of winners and
    losers, all districts should receive the resources they need to
    succeed.

                               PREPARED STATEMENT

        My bottom line today is that Iowans expect our schools and
    our teachers to receive the support they deserve. Please give
    us those resources, and I promise that we will attract and keep
    the brightest educators, and we will continue to educate the
    future of this great Nation.
        Thank you.
        [The statement follows:]

                        Prepared Statement of Chris Bern

        Thank you, Chairman Harkin, Ranking Member Cochran, and the members
    of the subcommittee for allowing me this opportunity to speak before
    you today. I applaud you, Chairman Harkin, and your subcommittee for
    holding this hearing today to discuss the urgent need for continued
    investment in education jobs. This hearing couldn't be timelier, as
    immediate action is needed to jumpstart local economies, and keep our
    schools fully staffed at a time when many students and families are
    experiencing great stress.
        My name is Chris Bern and I have been a public school teacher in
    Iowa for more than 30 years. I began my career teaching middle school
    math in Woodbine and moved to Knoxville, where I taught math at the
    high school, alternative high school, and middle school level over the
    years. Two years ago I was elected to serve as President of the Iowa
    State Education Association. I am proud to represent 34,000 dedicated
    educators in more than 350 school districts across Iowa.
        We are fortunate in Iowa to have some of the best public schools in
    the country. We have a long history of attracting the best and the
    brightest to teach in our schools and we have the graduation rates to
    prove that we are doing our jobs well.
        If educators are given the proper resources and supports, the sky
    is the limit on learning for our students. Study after study proves
    that the most important factors in a student's ability to learn are the
    skills and knowledge of teachers and education support professionals.
        Yet today, in Iowa and across our country, scores of talented,
    experienced teachers and education support professionals are at risk of
    losing their jobs due to historic State and local budget deficits. In
    fact, this spring, Iowa's teachers were faced with the threat of
    massive ``pink slips'' as the State's proposed budget dipped well below
    what schools' needs were. School superintendents throughout the State
    threatened massive layoffs as American Recovery and Reinvestment Act
    (ARRA) money was used up and State money did not fill in the gaps.
        I am very worried about what this means for our economy, as scores
    of research and common sense tell us that investments in education are
    inextricably linked to economic strength. More importantly, however, I
    am worried about what it means for our students.
        In our experience there are only two outcomes for a school district
    facing massive job losses: larger class sizes or the elimination of
    programs, both of which are detrimental to students. In Iowa and across
    the country, school boards and superintendents have released proposals
    to increase class sizes, and reduce program offerings. In Iowa, music,
    arts, and physical education programs were all on the chopping block.
    Class sizes ballooned and ``excess'' positions were proposed for
    elimination. Not surprisingly, parents and other concerned Iowans have
    been in an uproar, because they realize that Iowa's children will
    suffer. Iowans have gotten a glimpse of what these job losses might
    mean for their kids and they don't like what they see.
        Not one fewer student is coming through our doors because of the
    economic crisis. They still need us to be there helping them, inspiring
    them, and educating them every single day. The education jobs crisis is
    not only about adults, it is about our children, who get only one shot
    at an education and didn't ask to go to school during this time of
    economic crisis. Little Johnny still deserves the same quality
    education his sister got when she walked through our doors during
    better times.
        We got a small break this spring as our State revenue picture
    improved slightly. In the end though, the layoffs and the other cuts
    are expected to be as drastic as predicted. The picture will be clearer
    by the end of this month when our State requires layoff notices to be
    sent. But we know it will not be a pretty picture. We anticipate the
    number of teachers and education support professionals who will receive
    pink slips to be as high as 1,500. That's almost 4 percent of our
    education professional workforce in Iowa. That number doesn't even take
    into account the number of positions which will be lost due to
    retirements and attrition.
        The education investment in the ARRA was critically important to us
    in Iowa. It funded 6,715 education jobs in Iowa--teachers, librarians,
    nurses, support workers, as the most recent Department of Education
    report shows. Close to 5,000 of those jobs came as a direct result of
    the aid in the State Fiscal Stabilization Fund (SFSF). We desperately
    need this aid extended before the next school year.
        I want to tell you about one of my colleagues whose job was saved
    because of ARRA.
        Recently, we spoke to a special education teacher in Iowa City who
    was pink slipped last year. She split her time in two schools working
    with students needing individual educational assistance. Without her
    position, these students wouldn't get the one-on-one assistance and
    would most certainly fail. ARRA saved her job. She is now employed full
    time at Penn Elementary and continues her work with special needs
    students. What would the classroom be like without her and others like
    her? Who would help these students?
        We asked if she had lost her job last spring, would she have left
    the profession. She didn't know. We cannot afford that collateral
    damage either.
        So, how can the Senate help?
        First, the Senate needs to act quickly on an education jobs
    package. As you know, last December, the House of Representatives
    passed a jobs bill that included $23 billion for an Education Jobs
    Fund--essentially an extension of the SFSF in the ARRA. We project that
    bill would provide Iowa with enough emergency aid to help save or fund
    as many as 4,900 education jobs. Needless to say, this could go a very
    long way in helping to avert the crisis that is right in front of us.
        My colleagues back home asked me to come here to deliver a strong
    message--please act now to approve additional Federal aid targeted to
    help avert the looming layoffs that will reach into almost every Iowa
    community, threatening our economic recovery and our students'
    education.
        Leaving States to cut education more deeply--and we already are cut
    to the bone--without additional Federal aid is short-sighted. Lessening
    the quality of education a student receives today as a result may prove
    irreversible. Long-term productivity growth and a higher standard of
    living are dependent on an educated workforce.
        Second, I want to ask the Senate to look very closely at the
    administration's proposal to use competitive education grants to
    allocate Federal money. Formula grants provide a solid foundation for
    the resources needed to ensure a quality education. While that
    foundation has always been important, it has never been more so than in
    today's difficult economic climate. Our schools need a level of
    certainty and stability in funding that they can count on, without
    having to divert scarce time and resources to grant applications. Many
    of our rural districts would simply be unable to compete, as they do
    not have the staff to write grant proposals. We believe a competitive
    system serves only to create funding winners and losers, rather than
    providing all districts the resources they need to succeed.
        Chairman Harkin, Ranking Member Cochran, and the members of the
    subcommittee, my bottom line today is that Iowans expect our schools--
    and our teachers--to receive the support they deserve from the Federal
    and State governments.
        A lot of very smart people in Washington often talk about the next
    best thing to solve our Nation's education crisis. But, the answer
    isn't the next ``silver bullet'' to raise all test scores. It isn't the
    next greatest strategy to raise kids' reading skills. And, it isn't
    some magical test that will suddenly unlock every student's learning
    potential and every teacher's worth. I want to make one thing crystal
    clear: Teachers are not the problem here. We are the solution. We have
    been in the classroom each and every day teaching students. We just
    need the resources to do our work.
        So, please give us those resources to help ensure the fiscal
    stability of our educational system, and ensure that our schools stay
    fully staffed and I promise that we will attract and keep the best and
    brightest educators and we will continue to educate the future of this
    great Nation.
        The road to economic stability and prosperity for Iowa and our
    Nation runs through our public schools, and each and every student
    deserves the best we can offer.
        Thank you for the opportunity to provide this testimony.

        Senator Harkin. Thank you very much, Chris.
        And now we will turn to Dr. Joe Morton.

    STATEMENT OF JOSEPH B. MORTON, Ph.D., STATE
                SUPERINTENDENT OF EDUCATION, ALABAMA STATE
                DEPARTMENT OF EDUCATION
        Dr. Morton. Thank you, Chairman Harkin.
        My own Senator, Mr. Shelby, thank you.
        Thank you for inviting me to testify before the
    subcommittee today on the current fiscal crisis facing the
    States and its impact on education-related jobs across the
    country.
        I am Joseph B. Morton and have been introduced as State
    superintendent of education, and I am here representing
    Alabama. But also I represent the Council of Chief State School
    Officers, which is an organization that represents 50 State
    superintendents of education, the District of Columbia, the
    Department of Defense Education Activity, and 5 U.S. extra-
    State jurisdictions.
        And I am here to offer full support for a $23 billion jobs
    bill for education on behalf of my organization and my State.
    We need this money to keep our educators working.
        Unfortunately, as we all realize, State budgets lag behind
    a national recovery. In fact, in the Rockefeller Institute of
    Government report recently released, tax collections have
    declined for four consecutive quarters across the United States
    in State budgeting.
        States are now in the process of developing and finalizing
    fiscal year 2011 budgets. And without some kind of quick and
    near-term action, this continuing fiscal crisis will result in
    additional job cuts at a time when the Nation and Congress are
    centrally focused on the need for job creation and retention.
        I call your attention to my home State, as my own Senator
    Shelby has so eloquently already described, a State that is
    dependent on and very aware of the sensitivity to the economy
    because our educational activities in Alabama are funded on a
    statewide 4-cent sales tax and individual and corporate income
    taxes. So as the economy moves, so moves educational funding in
    Alabama.
        And as Senator Shelby outlined, we thought we were in good
    times in 2008 because in the spring of 2007, as we developed
    that 2008 budget, we had a record education budget of $6.7
    billion. We had 3.4 percent unemployment, which is still 73,000
    people. But it was low, and we thought things were good, and
    then the bottom fell out.
        And here we are today, $1.2 billion less in State funding.
    One point two billion dollars out of a $6.7 billion budget has
    gone away in State funding.
        Our schools and our State's schoolchildren and their
    families are hurting, and Alabama is not alone. Our
    unemployment rate today of 11.1 percent is 227,000 people that
    cannot find work. That impacts the education funding for our
    State.
        As of Monday of this week, I completed a survey of all 132
    school districts in my State, and based on the budget that was
    adopted last week by the Alabama Legislature, I asked local
    superintendents of education to tell me how many jobs would be
    cut based on that budget. My response came back, regrettably,
    that as our student population is increasing, we will lose
    1,599 teachers and administrators, and 1,228 support workers. A
    total of 2,827 fewer jobs in August of this year, as opposed to
    today.
        We know the California situation. We know that in Illinois,
    it is just as bad. Ten thousand layoffs already in Illinois,
    and another 10,000 predicted. We know that layoffs are all
    relative to the size of the district. I can tell you in our
    State of Alabama, there are counties that if they lay off 12
    people, that is equal to 1,200 in some districts. It is
    relative to the situation, and we have virtually every district
    in our State laying off people.
        Education, as we know, is a long-term investment. It
    strengthens the Nation's economy and, over time, provides a
    strong return on investment. We know that we need a jobs bill.
    We know that the ARRA, especially the SFSF, worked in our
    State, and it worked across this Nation.
        The University of Washington found that 342,000 jobs were
    funded by that ARRA. And we know in Washington State, 2,700
    jobs; South Carolina, 5,000; and in Alabama, we know that we
    can save with the continuation of that act 2,772 jobs.
        We have elected in our State to split the current ARRA SFSF
    over 2 fiscal years so we would avoid the worst of the funding
    cliff, and it still was not enough. Even with that, even with
    our budget of 2011 including one half of our SFSF, we still
    will lose 2,700 jobs.
        So, with that, may I conclude by saying that my
    association, the Council of Chief State School Officers, also
    supports in principle the blueprint for reform, but we have
    some questions. We have some interest in the detail of that,
    and at the expressed desire of the chair, I won't go into that
    at this time since this is more focused on a jobs bill.

                               PREPARED STATEMENT

        But let me conclude by saying that not only is it my strong
    personal--I offer my strong personal support, but I offer the
    support of 50 State superintendents of education for a jobs
    bill in our Nation and soon.
        [The statement follows:]

                        Prepared Statement of Joe Morton

        Chairman Harkin, Ranking Member Cochran, Senator Shelby, and
    members of the subcommittee, thank you for inviting me to testify
    before the subcommittee today on the current fiscal crisis facing the
    States and its impact on education-related jobs across the country. My
    name is Joe Morton and I am here today in my capacity as State
    Superintendent of Education for the great State of Alabama and as a
    member of the Council of Chief State School Officers, a national
    organization representing the State superintendents in all 50 States,
    the District of Columbia, the Department of Defense Education Activity,
    and 5 U.S. extra-State jurisdictions.
        As my time is limited, I will get right to the point, State
    governments continue to struggle with the budgetary challenges
    associated with the severe economic downturn this Nation has been
    facing since 2007. I'm here today in strong support of the House-passed
    Jobs for Main Street Act and its $23 billion extension of the State
    Fiscal Stabilization Fund. Schools need additional funding now or
    school boards will be forced to cut teaching and other key positions in
    our public schools. Fewer teachers in the classroom will only frustrate
    needed reforms in the Nation's persistently lowest-performing schools
    and the improvements that schools must make to ensure that all students
    leave high school ready for college and careers.
        Unfortunately, State budgets lag behind any national recovery by a
    year or more, so even as we are beginning to see economic growth at the
    national level, much State fiscal turnaround may still be some time
    away. In point of fact, the Rockefeller Institute of Government
    reported that State tax collections have declined for four consecutive
    quarters. Due to these revenue declines, 36 States were forced to cut
    more than $55 billion for fiscal year 2010 and 30 of those States cut
    both K-12 and higher education. Since the start of this recession,
    States have reported total estimated budget gaps of almost $430
    billion, and the Center for Budget and Policy Priorities reports
    remaining budgetary gaps of more than $140 billion just for the
    upcoming fiscal year.
        States are in the process now of finalizing their budgets for
    fiscal year 2011. Without near-term action, this continuing fiscal
    crisis will result in additional jobs cuts at a time when the Nation
    and Congress are centrally focused on the need for job creation and
    retention.
        I call your attention to my home State as a prime example of what
    is so prevalent in many States. Alabama is unique in many ways, but one
    is that it has two budgets to operate all State- supported agencies,
    programs, and institutions. The General Fund Budget funds all State
    agencies such as transportation, prisons, Medicaid, public safety, etc.
    The education budget funds all State-supported education endeavors from
    Pre-K to medical schools. Both funds have dedicated State taxes to
    support annual appropriations from the Alabama Legislature.
        In looking at education funding and personnel issues, one only has
    to look at the last four education budgets approved by the Legislature
    and to correspondingly look at State-unemployment figures for the same
    fiscal years. Realizing that the two largest education revenue sources
    used for funding the education budget are a statewide 4 cent sales tax
    and personal and corporate income taxes, it is readily apparent that
    the State education funding is directly tied to current economic
    conditions. Accordingly, if State revenues are lagging then
    correspondingly one would assume local school system revenues are
    lagging also. Of the 132 school systems in Alabama, 60 have established
    lines of credit from local banking institutions and either currently
    use this financial tool or will use it this fiscal year in order to
    meet payrolls and keep current on their monthly expenses.
        Funding for the past 4 fiscal years and the unemployment rates for
    those years shown on the following chart give a very clear and vivid
    indication as to why State education funding is in crisis in Alabama
    and why a jobs bill approved by Congress would be vitally important to
    educational progress in Alabama and across the Nation:

     ALABAMA EDUCATION BUDGETS AND UNEMPLOYMENT RATES--FISCAL YEAR 2008-2011
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Fiscal year 2008 Education budget           Unemployment rate in Alabama
    (Adopted Spring 2007)                       (February 2007)
    $6,729,089,656                              3.4 percent--73,551 people
    ------------------------------------------------------------------------
    Fiscal year 2009 Education budget           Unemployment rate in Alabama
    (Adopted Spring 2008)                       (February 2008)
    $5,693,326,351 (Includes a mid-year 11      4.1 percent--88,972 people
     percent reduction of funds)
    ------------------------------------------------------------------------
    Fiscal year 2010 Education budget           Unemployment rate in Alabama
    (Adopted Spring 2009)                       (February 2009)
    $5,322,329,577 (Includes a mid-year 7.5     8.7 percent--187,149 people
     percent reduction of funds)
    ------------------------------------------------------------------------
    Fiscal year 2011 Education budget           Unemployment rate in Alabama
    (Adopted Spring 2010)                       (February 2010)
    $5,495,772,478                              11.1 percent--227,717 people
    ------------------------------------------------------------------------

        A State survey conducted by my office of all 132 school systems,
    which concluded on April 12, 2010, indicates that even with a State-
    adopted education budget for fiscal year 2011, which includes the use
    of State Fiscal Stabilization Funds, there will be 2,827 fewer jobs in
    Alabama's K-12 public schools in August 2010 than exists today, even as
    the student enrollment increases. This is why Alabama educators support
    a jobs bill.
        Sadly, Alabama is not unique in this alarming regard. As has widely
    been reported, California sent 23,000 pink slip notifications out just
    last month. Illinois has already announced close to 10,000 teacher
    layoffs with an additional 10,000 predicted. Just 4 school districts in
    Mississippi combined to lose 160 teachers and a single school district
    in Wisconsin is planning to cut 50 jobs.
        In addition to the near-term impact these cuts will have on
    individual students, the reductions will also harm the Nation's
    productivity. Education is a long-term investment that strengthens the
    Nation's economy over time and provides a strong return on investment.
    For example, a recent study by the Alliance for Excellent Education
    found that cutting the dropout rate in the Nation's 50 largest cities
    in half would lead to $536 million in increased tax revenue, an
    additional $2.8 billion in spending and more than $4 billion in
    increased earnings per year. Given these profound figures, education
    must be among the highest-priority investments for the country even
    during challenging budgetary times.
        There is no doubt in my mind that the current crisis would have
    been far worse if not for the significant education funding provided by
    Congress for the American Recovery and Reinvestment Act and the State
    Fiscal Stabilization Fund (SFSF) more specifically. What we know is
    that SFSF worked. A recent study by the Center on Reinventing Public
    Education at the University of Washington found that more than 342,000
    jobs are funded by the Recovery Act. SFSF funds paid for 2,700
    education jobs in Washington State alone and almost 5,000 in South
    Carolina.
        Since we know that the SFSF worked, an extension is not only
    logical but urgently needed to help sustain our commitment to education
    reform and improvement. Estimates of the proposed SFSF extension would
    provide an additional $345 million for the State of Alabama, funding an
    estimated 4,150 education jobs. New Hampshire would see an additional
    $95 million and save 2,000 jobs, and Tennessee would see almost $450
    million for an estimated 1,700 education jobs. In total, the House-
    proposed extension would fund 250,000 education-related jobs across the
    country.
        In spite of the current economic crisis and the challenges facing
    State governments, American education is experiencing a period of
    significant transformation and reform. States are focused like never
    before on strengthening standards and assessments, improving systems of
    educator development, and developing comprehensive data systems and the
    next generation systems of learning. As you know, CCSSO, in
    collaboration with the National Governor's Center for Best Practices,
    is close to finalizing the common core standards for college and career
    readiness in Mathematics and English Language Arts. This historic step
    is but one of many groundbreaking reforms that States are undertaking
    to develop coherent birth-to-20 high-performing systems of
    comprehensive reform that promote continuous improvement at all levels
    of the education spectrum.
        To make these efforts fully come to fruition though, we need a
    stable funding stream and a new State-Federal partnership--through the
    reauthorized ESEA--to help ensure Federal investments keep pace with
    the changing landscape and the increased role of the State as leading
    comprehensive reform. The President's proposed budget is a strong
    starting point, but State chiefs would like to highlight several areas
    in need of greater investment.
        First, current funds for student assessments are woefully
    inadequate to develop high-quality summative assessments, let alone to
    develop the next generation of formative and interim assessments. The
    $350 million Race to the Top Assessment set-aside is appreciated, but
    long-term funding is needed within ESEA to implement and sustain any
    product of this new competition.
        Second, States recognize the need for focus and attention on the
    persistently lowest-performing schools through concerted school
    improvement interventions. But as SEAs now play the central role in
    providing technical assistance and other supports to their struggling
    districts and in many cases directly intervene in schools that are
    chronically underperforming, States are very hopeful that Congress will
    provide additional resources. Building State-level capacity is an
    essential component to statewide school turnaround.
        Third, State chiefs understand and appreciate the value of new
    competitive grant programs as a catalyst for driving reform, but we
    implore the Congress to view those increases as above and beyond core
    funding for key formula programs like title I, IDEA, and State
    Longitudinal Data Systems. These investments are needed to ensure that
    all students, regardless of income, race, special needs, or other
    characteristics, are receiving a high-quality education.
        Lastly, let me say that State chiefs strongly support the
    Department's proposed consolidation of programs into 11 more coherent
    funding streams. Such an approach will provide States with increased
    flexibility to target resources toward the greatest areas of need. This
    change will certainly enable States to better allocate Federal
    resources and will also eliminate redundant reporting.
        In closing, let me again issue my strong personal support and that
    of the other chief State school officers around the country for an
    education jobs fund. It is needed and it will pay dividends.
        Thank you again for inviting me to testify before the subcommittee
    today. I look forward to answering your questions.

        Senator Harkin. Thank you very much, Dr. Morton.
        Dr. Morton. Thank you.
        Senator Harkin. Very eloquent statement. And now we turn to
    summarize things up here, Mr. Herzog. Welcome.

    STATEMENT OF MARC S. HERZOG, CHANCELLOR, CONNECTICUT
                COMMUNITY COLLEGES
        Mr. Herzog. Thank you, Chairman Harkin, Ranking Member
    Cochran, and distinguished members of the subcommittee, we
    thank you for this opportunity to appear before you today.
        My name is Marc S. Herzog, and I am the chancellor of the
    Connecticut Community Colleges. I am also here today on behalf
    of the American Association of Community Colleges, which
    represents the Nation's approximately 1,200 community colleges,
    which are currently enrolling almost 8 million students.
        The Connecticut community college system is a State system
    of publicly supported 2-year colleges. This is a precarious
    time for community colleges. Our ability to sustain the current
    level of education services and to respond to the enormous
    demands being placed on us carries with it a profound long-term
    economic implication.
        Community colleges play a significant role in the education
    and skill building of the American workforce. And certainly,
    that has been recognized by President Obama, who has challenged
    community colleges to graduate 5 million more students by the
    year 2020.
        Enrollments in the Nation's community colleges have surged
    dramatically during this recession. Credit enrollments have
    risen in the last 2 years by 16.9 percent. That is 1.2 million
    students. These dramatic enrollment increases have caused our
    colleges to literally scramble to expand our course offerings
    and student support services while undergoing cuts in public
    funding, which have been averaging 4 percent per year in each
    of the last 2 years.
        Despite every budgetary strategy imaginable, doing more
    with less, we believe that hundreds of thousands of individuals
    have effectively been denied access to community colleges over
    the last 2 years because of the lack of availability of program
    offerings. This is really a national tragedy because community
    colleges serve students who frequently have no other option to
    attend college but a community college.
        Let me turn to the situation in Connecticut, since it
    reflects what is actually occurring nationally. Let me also add
    that there are many 4-year public institutions in higher
    education that face a similar situation.
        Connecticut's community colleges are serving more than one-
    third more students today than we did a decade ago. We have an
    increase of more than 58 percent in full-time equivalent
    enrollment. That is actually the measure of the amount of
    teaching that is going on in our classrooms today of a count of
    credit hours.
        We serve 50 percent of the undergraduates in public higher
    education, and we serve two-thirds of the minority students
    attending public higher education. Last fall, our enrollments
    grew by 10 percent at a time when our system budget declined by
    more than 10 percent.
        Our State general fund support for public higher education
    is funded at maintenance of effort level in compliance with the
    ARRA SFSF. The Federal ARRA SFSF in Connecticut was used to
    preserve educational services in the K-12 sector. But despite
    the stimulus funding, the State of Connecticut today, this
    fiscal year, is still facing a $500 million deficit with a $700
    million adjustment still necessary for the next fiscal year,
    fiscal year 2011. And the State is expected to face a $4
    billion shortfall in the next biennium.
        Given this and similar situations across the country, we
    need to help avoid I believe what you termed earlier, Senator
    Harkin, the cliff. We support and urge the enactment of a Keep
    Our Educators Working Act, which dedicates $23 billion to
    retaining, hiring, and training educational personnel. At
    almost 70 percent of the total budget for community colleges
    are devoted to labor costs, this legislation becomes critical
    for our institutions.
        Mr. Chairman, we thank you for your leadership on this
    issue and for recognizing the importance of supporting public
    K-12 and higher education in our hour of extreme need. We
    believe that without substantial Federal investment in
    education jobs, that faculty, academic, and institutional
    support staff and administrators will be laid off in many
    States. But more importantly, thousands of students of all ages
    will lose opportunities to gain education and skills needed to
    turn around our economy and to contribute to America's future
    prosperity.
        We understand the tremendous constraints that Congress is
    operating under, but we see no alternative to some form of
    Federal assistance.
        Finally, in addition to the Keeping Our Educators Working
    Act, there are numerous Federal education and workforce
    programs that are essential to community colleges. Let me just
    comment very briefly on three.
        The Pell Grant program, which we are thankful to this
    subcommittee for your support. Pell Grants provide the
    opportunity to attend higher education for a significant
    portion of our population. One-third of the population today
    receiving Pell Grants attend an American community college.
        The strengthening institutions program included in the
    title III act of the Higher Education Act, this program will
    clearly provide a great force for institutional improvement.
        And last, the Career Pathways Innovation Fund, which the
    Obama administration has proposed eliminating, this program,
    under its previous name, the Community Job-Based Training
    Grants Program, has had a very positive impact on community
    colleges and our local economies, and it would be very
    shortsighted to terminate it.

                               PREPARED STATEMENT

        Mr. Chairman, I thank you for this opportunity to appear
    before you today, and I certainly would be happy to respond to
    any questions you might have.
        Thank you.
        [The statement follows:]

                      Prepared Statement of Marc S. Herzog

        Chairman Harkin, Ranking Member Cochran, and distinguished members
    of the subcommittee, thank you for the opportunity to appear before you
    today. My name is Marc S. Herzog and I am the chancellor of the
    Connecticut Community Colleges.
        The Connecticut community college system includes 12, 2-year public
    colleges with a shared mission to make educational excellence and the
    opportunity for lifelong learning affordable and accessible to all
    Connecticut citizens. The colleges provide general education programs
    for career enhancement; transfer programs to expand access to 4-year
    degrees; developmental education programs to reduce academic barriers;
    student services to enhance student success; community service
    programs; and career education for jobs in such areas as nursing and
    allied health, information technology, emergency services, and early
    childhood education. Together these colleges provide the State of
    Connecticut with a solid, statewide foundation for higher education and
    workforce development.
        I am here today on behalf of the Connecticut Community Colleges and
    the American Association of Community Colleges (AACC), which represents
    the Nation's 1,177 community colleges. Rising enrollments, declining
    State and local funding, and the economic freefall have presented a
    veritable crisis for our colleges. Without substantial financial
    investments in education jobs, not only will faculty and administrators
    be laid off in many States, but thousands of students of all ages will
    lose opportunities to gain the education and skills needed to turn
    around our economy and contribute to America's future prosperity.

                                ENROLLMENT SURGE

        Typically, enrollments in postsecondary education increase during
    difficult economic times. Enrollments at the Nation's community
    colleges have surged dramatically, with credit enrollments rising 16.9
    percent over the last 2 years, to approximately 8 million credit
    students, just under half of the Nation's undergraduates. Full-time
    enrollments (FTEs) increased by 24 percent over the same period. These
    unprecedented enrollment increases have been fueled both by new high
    school graduates and adult learners returning in droves to community
    college classrooms.
        For younger students and their families, lower tuitions at
    community colleges make them an affordable option; the average tuition
    for a full-year, full-time student is just $2,544, which enables most
    community college students to avoid debt entirely. For older students,
    unemployment and threats of job loss reinforce the importance of
    college degrees and new skills training to secure employment in today's
    highly competitive market. Both new graduates and adult learners
    benefit from the partnerships community colleges continue to forge with
    business and industry.
        These dramatic enrollment increases have presented many challenges.
    Colleges have been scrambling to expand their course offerings despite
    serious budget constraints, and students have learned that they must
    apply early for financial aid and register in advance for classes.
    Nevertheless, we believe that hundreds of thousands of individuals have
    effectively been denied access to community college over the last 2
    years due to the unavailability of program offerings. This is a
    national tragedy. While very few community colleges cap enrollments or
    admissions outright, this is done in the de facto policy when students
    cannot access the programs they need.
        These access issues carry with them profound long-term economic
    implications for the country. On average, community college graduates
    earn 23 percent more annually than those who only hold a high school
    diploma.
        In Connecticut, community colleges are serving more than one-third
    more students than they were a decade ago, with double digit increases
    in enrollments system wide this academic year. Community colleges serve
    as the point of entry into higher education for more than 50 percent of
    Connecticut's undergraduates in public higher education, including two-
    thirds of the State's minority undergraduates. Last fall, a record-
    breaking 55,112 headcount students registered for credit courses at the
    Connecticut Community Colleges. Another 35,000+ students will enroll in
    noncredit programs throughout the year with approximately 50 percent of
    these students focusing on acquiring the skills required by the State's
    employers and the workforce of the 21st century.

                    STATE BUDGET CRISIS AND STIMULUS FUNDING

        The economy in Connecticut, the State budget and the budget for
    higher education, continue to face enormous challenges, particularly
    within the community college sector where enrollment growth has
    consistently exceeded that of other public and private colleges. In
    Connecticut, our college funding comes from tuition and fees, Federal,
    State, and private grants, and the State's general fund. Last fall
    enrollments grew by approximately 10 percent at a time when the college
    system's budget had declined through reductions and rescission by more
    than 10 percent.
        The Connecticut community college system budget for the current
    year is just below the fiscal year 2008 funding level. State general
    fund support for public higher education is funded at maintenance of
    effort levels in compliance with the American Recovery and Reinvestment
    Act (ARRA) State Fiscal Stabilization Funding (SFSF) requirement.
    Federal ARRA State fiscal stabilization funding was used to preserve
    the State's educational services in the K-12 sector. Despite the influx
    of Federal stimulus funding, the State is facing a $500 million deficit
    in the current fiscal year with a shortfall of $700 million projected
    for the fiscal year 2011. In the 2012-2013 biennium, with stimulus
    funding exhausted, the State will face a $4 billion deficit.
        The Connecticut community colleges have exerted extraordinary
    efforts to absorb and serve the expanding enrollments and growing
    educational needs of the students who have turned to them in the last 2
    years--16.8 percent more FTE students since 2008, with a budget below
    the fiscal year 2008 level. While additional students bring added
    tuition revenues, they also bring increased demands that must be met
    with reduced resources. Colleges raise tuition modestly each year in an
    effort to balance student access and affordability with unavoidable
    cost increases.
        The capacity of our colleges is stretched to the breaking point and
    the continued growth that we anticipate in the next 2 years and beyond
    cannot be met without adequate funding support. Yet higher education is
    frequently looked to as the ``balance wheel,'' according to a report
    from the American Council on Education, in the State budget process,
    particularly when budgets are in decline and demand for services are
    growing. Unfortunately, the burdens of the current economy and the
    heavy weight of economic forecasts are pushing any attempt at balance
    beyond the tipping point.
        In virtually every State, community colleges as well as the 4-year
    public colleges and universities face State funding reductions. Despite
    rising enrollments, these State budget cuts have led to layoffs,
    furloughs, reduction in hours for adjunct faculty, and hiring freezes.
    Colleges are stretching services to the limit, and, in many places,
    turning students away.
        The ARRA SFSF has helped to blunt what would have been even deeper
    State budget cuts to education. According to a recently released report
    by the State Higher Education Executive Officers, 15 States used ARRA
    funds in fiscal year 2009 ``to cover operational shortfalls, accounting
    for 3 percent of total State and local support for higher education.''
    In fiscal year 2010, SFSF funding comprised 10 percent of all higher
    education funding in 9 States. Community college leaders in several
    States report that ARRA funds have helped them avoid significant
    layoffs, temper tuition increases and serve more students. But, these
    same officials are deeply concerned that public higher education is
    facing a budget cliff with the expiration of ARRA funding. A few
    examples:
      --Community colleges in Iowa received $23.1 million from the SFSF and
            $2.5 million from the government services funds (total of $25.6
            million) in fiscal year 2010. There were no funds in fiscal
            year 2009 and there are no funds for fiscal year 2011. These
            funds were used to avoid layoffs and reduce tuition increases
            in fiscal year 2010. As an example, for the July 1, 2009-March
            31, 2010 time period, a total of 257 full-time equivalent
            employees were retained as a result of this funding (401,106
            hours worked). Even with this ARRA support, State
            appropriations for community colleges will have decreased by 13
            percent between fiscal year 2009 and fiscal year 2011.
      --In Colorado, ARRA funds were used to revert a 49.5 percent cut in
            State appropriations to community colleges in fiscal year 2009-
            2010. ARRA funds and the ARRA maintenance-of-effort (MOE)
            requirements will help to blunt cuts to the colleges in fiscal
            year 2010-2011, though they still face a cut of 7.2 percent
            that would have been 17.8 percent without ARRA funds. Looking
            ahead to fiscal year 2011-2012, without the same MOE
            requirements in place and having already expended its ARRA
            funds, the Colorado community colleges fear deep cuts are in
            store for them without another direct infusion of Federal
            funds.
      --The Alabama Community College System received approximately $35
            million in ARRA funds, split evenly between fiscal year 2010
            and 2011. These funds have helped to mitigate (but not
            eliminate) the need to raise tuition and fees and have saved
            341 jobs. The ARRA funds have also allowed the Alabama system
            to serve more students and avoid enrollment caps.
      --In Washington, $8.5 million in ARRA funds helped to restore a 9
            percent cut to community colleges in fiscal year 2009-2010,
            allowing them to serve 1,500 FTE students. ARRA funds and the
            MOE requirements have also muted potential budget cuts for
            fiscal year 2010-2011, but the colleges are still expecting a
            4-5 percent cut. Here, too, college officials are very
            concerned about profound budget cuts once the ARRA funds are
            expended.

                              EDUCATION JOBS BILL

        Given that State tax revenues are not likely to recover in time,
    community colleges and other public higher education institutions
    desperately need additional Federal resources to avoid this anticipated
    ``cliff'' effect in many States. For this reason, AACC urges enactment
    of legislation containing an ``Education Jobs Fund,'' as in the
    legislation introduced today by Senator Harkin and the original House-
    passed ``Jobs for Main Street Act.'' Action of this nature is needed in
    order to avert major cuts on many of our campuses, which in turn will
    lead to a further denial of access to our programs. Approximately 70
    percent of the total budgets of community colleges are devoted to labor
    costs. Without enactment of the ``Keep Our Educators Working Act'' or
    similar legislation, it is unclear how many community colleges will
    manage.
        The proposed legislation would create a $23 billion ``Education
    Jobs Fund,'' like that in the SFSF to help States and localities retain
    teachers and faculty. We appreciate the recognition of the importance
    of both K-12 and higher education funding in this legislation. Further,
    with the inclusion of MOE language, the legislation should ensure that
    the Federal investment in public education will achieve its full and
    intended impact.

                            FISCAL YEAR 2011 FUNDING

        Numerous Federal education and workforce training programs are
    essential to community colleges and the students they serve, providing
    critical student financial aid, institutional support, and resources to
    train workers for highly competitive jobs. Many of these initiatives
    also help community colleges hire and retain faculty for specific
    programs. The recently enacted budget reconciliation legislation
    provides significant investments in Federal student aid and
    institutional assistance, as well as funding for the Community College
    and Career Training Grant program, a new Trade Adjustment Assistance
    program that was created (but not funded) by ARRA.
        The following represents some of the funding priorities for
    community colleges for fiscal year 2011.

                         THE FEDERAL PELL GRANT PROGRAM

        A record number of students are relying on Federal Pell Grants.
    Nearly 9 million college students, approximately one-third of them
    attending community colleges, will receive Pell Grants in fiscal year
    2011. For community college students, the Pell Grant program remains by
    far the most important student aid program.
        Community colleges are grateful for the significant investments
    made in the Federal Pell Grant program under provisions contained in
    the recently enacted budget reconciliation legislation. These increases
    will enhance access and help students steer clear of debt. The
    Connecticut Community Colleges have disbursed $59.1 million in Federal
    Pell Grants this academic year, an increase of 59 percent in 1 year, to
    more than 21,000 students, an increase of 34 percent. More than 5,000
    of these Pell recipients were unemployed or had a spouse who was
    unemployed; and 13 percent of the dependent student recipients reported
    at least one parent was unemployed.

             FEDERAL STUDENT SUPPORT SERVICES AND INSTITUTIONAL AID

        In addition to the Federal student aid and student support services
    (such as TRIO and GEAR UP), community colleges strongly support funding
    for institutional aid under titles III and V of the Higher Education
    Act (HEA). Two point fifty-five billion dollars of additional funding
    is provided for minority-serving institutions (MSIs) over the next
    decade in the recent budget reconciliation legislation. AACC continues
    to support funding for the MSIs and advocates for additional resources
    for the strengthening institutions program. Strengthening institutions,
    contained in title III-A of the HEA, tends to be overshadowed by other
    institutional aid programs, but is an extremely effective program that
    benefits from healthy competition each year.

                PERKINS CAREER AND TECHNICAL EDUCATION PROGRAMS

        Perkins Career and Technical Education (CTE) programs are the
    largest Federal source of institutional support for community colleges,
    helping them to improve all aspects of cutting-edge career and
    technical education programs. In his fiscal year 2011 budget, President
    Obama proposed the consolidation of the tech prep program into the
    basic state grants and level funding of Perkins CTE. AACC supports the
    preservation of the tech prep program and increasing total funding to
    $1.4 billion for the Perkins CTE programs.

                        CAREER PATHWAYS INNOVATION FUND

        AACC urges the subcommittee to continue to fund the Career Pathways
    Innovation Fund. This program, formerly the Community-Based Job
    Training Grants (CBJTG), serves a vital need by expanding the capacity
    of community colleges to train workers for jobs in high-demand, high-
    growth industries. Since its inception in fiscal year 2005, this
    program has brought together community colleges, local businesses, and
    Federal workforce investment boards to prepare workers for employment
    in industries such as healthcare, advanced manufacturing, and
    technology. While the administration's budget proposed eliminating the
    program because it duplicated the proposed American Graduation
    Initiative (AGI), AGI was not enacted and the resources provided by
    this program, which provides both immediate training and some funding
    for longer-term program development, are sorely needed. AACC strongly
    supports the continuation of this program with at least $125 million in
    fiscal year 2011.
        Connecticut is the only State in the Nation to receive awards in
    all four rounds of the CBJTG program. Credit certificate programs
    combine academic and technical skills with occupational specialty
    courses developed with input from each industry to ensure relevance to
    employer needs. The most recent grant focuses on energy efficiency and
    conservation to advance Connecticut's Energy Vision, which mandates
    that, by 2020, at least 20 percent of Connecticut's power will be
    supplied by renewable sources.
        Grant funded initiatives have increased the number of students
    succeeding at the college level and entering growing fields of
    employment in the State. Connecticut Department of Labor data indicate
    that earnings for students in targeted degree programs served by two of
    the grants (nursing, respiratory care, physical therapy assistant,
    radiologic technician, and medical assistant) increased from $23,626 in
    2005 to $57,740 in 2008--a 144 percent increase.

                                   CONCLUSION

        Numerous studies show that there is a strong positive correlation
    between educational attainment and income. The average community
    college graduate earns about $7,000 more each year than someone who has
    only a high school education. The ``middle skills'' jobs for which
    community colleges provide preparation are expected to grow robustly
    over the next decade.
        Investments in education jobs provide both short-term and long-term
    benefits by preserving faculty jobs, expanding education and training
    opportunities at the postsecondary level, and helping Americans attain
    the postsecondary degrees and credentials that will drive our future
    economy.
        Thank you, Mr. Chairman and members of the subcommittee, for this
    opportunity to speak with you today.

        Senator Harkin. Thank you, Mr. Herzog. Thank you all very
    much for your eloquent statements.
        I think it is worth noting that we just heard from a
    teacher from Iowa; a superintendent from the second-largest
    school district in the United States, Los Angeles; a State
    school chief from Alabama; and a community college chancellor
    from Connecticut. You basically all said the same thing.
        The jobs crisis in education is real. This is not something
    ``maybe if.'' It is happening right now, and it is real. And it
    is not just a problem in one State or one area. It is a problem
    nationally.
        Now, let me get to one point rapidly that came up earlier,
    and it will come up again. The bill that I am putting in today
    is deemed an emergency bill, which means it is not offset by
    spending cuts someplace else. We are in an economic mess right
    now.
        Some people have said, wait a minute, you are going to
    borrow from our kids and our grandkids to pay for this now?
    That shouldn't be. We are borrowing too much from our kids and
    grandkids.
        Well, quite frankly, I agree we are borrowing too much from
    our kids and grandkids. We have a terrible deficit problem,
    debt problem--debt and deficit problem. But it seems to me this
    is targeted only for education. How can you argue on the one
    hand that it is okay for a kid to borrow to go to college, but
    it is not all right to borrow to make sure that there is a
    college for the kid to go to? That there are teachers in our
    high schools and in our grade schools to prepare these kids for
    the future?
        It seems to me if there is one legitimate area where we can
    borrow from the future, it is in education. Because what kind
    of jobs will my grandkids and great-grandkids have if we don't
    have a well-educated group of young people today who will be
    providing the leadership and the technology and the innovations
    and the job creations and the business leadership that will
    provide those jobs in the future?
        So you can argue about borrowing from the future for this
    or that. There are a lot of legitimate arguments on that. Some
    of it I don't care much about either. But in this one area, it
    seems to me this is legitimate. To ask our unborn in the future
    to help pay for the education of their--of what will be their
    grandparents and great-grandparents today so that they will
    have a better future then.
        So I wanted to get to that because if we are going to get
    bogged down in taking money from here and there, and we are all
    in this mess right now, an economic mess. We will be here for
    the next 2 years, 5 years debating that.
        We have a real cliff problem right now. And as I said, it
    is happening. You testified it is happening. Pink slips are
    going out now. It is April, May. That is when the decisions are
    being made. We don't have the luxury of waiting--well, maybe
    this fall we will get to it. That is too late. Or next winter.
    That is too late.
        This is a real crisis that we have, and that is why I
    appreciate your sort of bringing this to a head from all
    different sectors--large, small, community colleges, chief
    State school officers all over this country--because it is a
    national problem.
        And I must as, as the chairman of this subcommittee and the
    chairman of the education authorizing committee, there is not
    enough being said about this nationally. It is sort of like it
    is there. We know it is going to happen and it is happening,
    but there is not much focus on that in the national press.
        I will tell you when the focus will happen. If we don't do
    anything and we wind up next fall, and all of a sudden classes
    are cut, school years are being decimated, and teachers are
    sent home when we don't have enough bus drivers to get our kids
    in rural Iowa to the schools because they had to lay off the
    bus drivers. When we have had to cut back maybe on school lunch
    programs because we can't hire the cafeteria workers.
        Oh, yes. You will get a lot of publicity then, folks. There
    will be a lot in the press, a lot on TV. And where was
    Congress? Where were we? Asleep at the switch?
        Well, we can't just respond to something simply because it
    is popular in the press right now. I think one of our
    obligations as elected officials is to anticipate, think about
    what we have to do now to keep from having these bad things
    happen down the road.
        Well, I have got 38 seconds left to ask a question. I
    guess, if anything, I would again ask you all just any general
    comments you have on who is going to be laid off and what you
    see out there if we don't act now? If you just have any
    response to that at all? You have kind of covered it, but if
    you have any specific things that you didn't mention in your
    testimony.
        Mr. Cortines.
        Mr. Cortines. No, I think we do have to look at all, and
    you have covered that. And even though I represent a very
    large, urban system, when you say ``all,'' that means rural
    America also. That means the mid-size also.
        And it does mean not just teachers and administrators, it
    means custodians and cafeteria workers and secretaries. It
    takes all of those wraparound services to make for a good
    comprehensive educational environment.
        Senator Harkin. Mr. Bern.
        Mr. Bern. And I would just add it is happening all over the
    State. I mean, we have teachers living in fear, not knowing
    whether they are going to have a job--not just teachers,
    support workers, bus drivers, cooks, secretaries, and everyone
    is living in fear right now because they don't know.
        Our legislature did pass a budget just recently, but before
    that, we had superintendents planning for the worst-case
    scenarios. And in Des Moines, they were talking about 300 job
    cuts. Thankfully, our legislature found some money, and so
    things aren't going to be quite as bad. But the Des Moines
    school system just passed a budget last night, and they are
    going to be cutting 171 positions. So help is desperately
    needed.
        Senator Harkin. When you said for our entire State, you
    mentioned 1,500?
        Mr. Bern. That is our estimate right now, 1,500 positions.
        Senator Harkin. Dr. Morton.
        Dr. Morton. I would just point out one thing. And I look at
    a jobs bill as an investment, and I know people worry about
    their 401(k)'s and their retirement. I think people in this
    Nation ought to worry about the dropout rate and who is going
    to work and are they going to be able to work?
        And with this jobs bill, we will have teachers that could
    stay on the job and work with young people to keep them in
    school. And if you look at the Alliance for Excellent
    Education, they have a model for every State, and what would be
    saved and what would be added back to the economy of that State
    if we could reduce our dropout rate and increase our high
    school graduation rate so they could go on to a community
    college or a 4-year college and get a job and be a productive
    citizen.
        And we know just from their information that if we could
    reduce the dropout rate by half in the 50 largest cities in
    America, it would increase the increased earnings per year by
    $4 billion, and that is just in 50 cities. So think of the
    Nation and what could happen with this investment, and that is
    the way I look at it, as an investment.
        Senator Harkin. Very good.
        Mr. Herzog. Senator, in our system, we have already lost
    177 people this year. The kinds of services that you lose are
    hours of access to a college library, laboratories, all of
    those academic instructional support services that students
    need.
        At the same time, where access to community colleges has
    never been greater, our goal is to have success at our
    colleges. And the very people that we need to support students
    are the very people that will go.
        Senator Harkin. Thank you all very much.
        I will go to my good friend, Senator Shelby.
        Senator Shelby. Thank you, Mr. Chairman.
        I think it is very important, and you have done this, you
    have focused, among other things, on the loss of teachers and
    support and so forth. That is important. But we should never,
    never lose focus on the student. Of course, it is related to
    that, and nobody knows that better than the four of you.
        But because what do we care about? We care about everybody,
    but we care about that student getting a quality education to
    be ready for the workforce. And they are not going to get there
    on their own, and I think you are pointing that out.
        Dr. Morton, one of your initiatives, and I mentioned it
    earlier, and you got a lot of credit, and rightfully so, for it
    is the Alabama Math, Science, and Technology Initiative. And in
    light of our Nation, not just our State, but the whole Nation's
    need to stay competitive with other countries and try to be a
    world leader in math, science, and high biotech-related
    industries and research, what was your reaction to the Race to
    the Top application from the Department of Education and, my
    understanding, allocation of 15 out of 500 points to that
    topic?
        That seems to be low and is troubling to me, 15 out of 500
    points----
        Dr. Morton. Senator Shelby----
        Senator Shelby [continuing]. Which will drive the industry
    and the Nation and the world in the future.
        Dr. Morton. Our whole initiative was built on the fact that
    we think that America and Alabama students, their future is in
    math and science and technology.
        Senator Shelby. Absolutely.
        Dr. Morton. We know that President Obama campaigned on it.
    And I, quite frankly, was stunned when I opened the criteria
    for Race to the Top and had been--we had invested a lot of
    money and effort, and we are not going to back away from that
    investment. I think it is the right investment.
        Senator Shelby. You can't.
        Dr. Morton. We got Huntsville, and we got UAB in Birmingham
    and Mobile, and we are going to stay behind that investment.
    But I was stunned and disappointed to find that out of 500
    possible points for Race to the Top, only 15 points, 3 percent
    of the whole application dealt with science, technology,
    engineering, and mathematics, the STEM.
        I don't get--there is a disconnect there I don't----
        Senator Shelby. Absolutely. And it seems like it is upside
    down. This needs to be changed.
        Dr. Morton. It did not open the door for America to walk
    through and not be 20th or 25th in the world in 14-year-old
    math and science scores. If we are going to be number one, we
    have got to invest in engineering, mathematics, technology,
    biotech.
        And Race to the Top, $4.3 billion, allotted 3 percent, 15
    out of 500 points to that topic. I was very disappointed.
        Senator Shelby. I think it was a flawed program. You do,
    too, that it was?
        Thank you. Thank you, Mr. Chairman.
        Senator Harkin. Very interesting.
        Dr. Morton. Yes, sir. I would----
        Senator Harkin. You learn something new every day around
    here.
        Dr. Morton. I think our Nation would be honored if someone
    would kind of look into that.
        Senator Harkin. Well, I think we will look into that.
        Dr. Morton. Thank you.
        Senator Harkin. Okay. Let me get that. Five hundred points,
    and only 15----
        Dr. Morton. Three percent are on STEM--science, technology,
    engineering, and mathematics education.
        Senator Harkin. Hmmm.
        Senator Shelby. Mr. Chairman, I wish you, as chairman of
    this subcommittee, would look into this, and I think you will
    have a lot of support on both sides of the aisle, Democrats and
    Republicans.
        Senator Harkin. Well, Dick, let us work together. Let us
    find out. That doesn't sound--this shouldn't be. It should be
    higher.
        Senator Shelby. That is the way it is set out, isn't it?
        Dr. Morton. Yes, sir. That is the way the criteria break
    out.
        Senator Shelby. Thank you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. Well, thank you. Thank the panel. Thank you
    all very much, and we will do everything possible and ask for
    your continued involvement and help in this effort.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                    Questions Submitted to Hon. Arne Duncan
                Questions Submitted by Senator Mary L. Landrieu

                                RACE TO THE TOP

        Question. The administration has requested $1.35 billion to extend
    the Race to the Top competition. In the first round of this year's
    competition, you selected only the States that demonstrated
    exceptionally high levels of statewide support from superintendents,
    school board presidents, teachers' unions, and charter schools. As you
    are well aware, real reform too often encounters resistance from some
    teachers' associations and school boards. Proven results are often the
    only meaningful way to convince the doubters. Therefore, I believe that
    supporting real reformers is a smarter strategy, whether or not the
    reform plan has near unanimous stakeholder buy-in.
        Also, there has been some discussion about the Race to the Top
    scoring process. For example, six first-round finalist applications--
    including the application from my home State of Louisiana--saw a
    particularly wide gap between their highest and lowest scores.
    According to a recent report by The New Teacher Project, throwing out
    the highest and lowest scores of each State application would have
    dramatically changed the rankings for applications from finalist States
    like Louisiana and Georgia. Some have suggested that a broader range of
    reviewers could help to dampen the impact that only one negative review
    would have. Others have suggested clarifying whether the criteria are
    objective or comparative.
        As you approach Round Two of the Race to the Top and as we consider
    funding an additional $1.35 billion for next year, how might you change
    the evaluation criteria to support bold reform and ensure a fair
    scoring process?
        Answer. While I understand your concern about the potential for
    tradeoffs between, on the one hand, proposing serious reforms and, on
    the other, gaining stakeholder support, we believe that States should
    make every effort to both craft ambitious reforms and engage affected
    stakeholders and leaders in making the reforms a reality. We do not
    believe that ambitious reform and stakeholder support are mutually
    exclusive. It is important to note that, while the two phase 1 winners,
    Delaware and Tennessee, did have high levels of stakeholder support,
    this buy-in did not soften their reform efforts. It is also worth
    noting that a number of highly rated phase 1 States that fell just
    short of winning phase 1 awards had strong conditions and plans for
    reform with lower levels of stakeholder support. The message, I hope,
    is that we are not in favor of weakening reforms in order to strengthen
    stakeholder support; however, we do acknowledge that on-the-ground
    reforms in education, to be successful, require the active
    participation of school leaders, teachers, and other stakeholders. The
    Race to the Top criteria and scoring system are designed to incent and
    reward programs that are ambitious yet achievable.
        Regarding your concern about a single reviewer on a panel affecting
    the competition's outcome, I would observe that any diversity of
    opinions among reviewers was the product of a rigorous review process:
      --Each of the 58 reviewers was carefully chosen for his or her
            expertise from a pool of approximately 1,500 applicants.
      --For tier 1, each reviewer spent roughly 30 hours reading each
            application, and then discussed each application in detail with
            his or her panel. To facilitate these discussions, we provided
            each panel with a measure of the variation between individual
            reviewers' scores for each criterion on that application. This
            allowed reviewers to quickly identify and focus their
            discussions on differences in scores, and to ensure that those
            differences were based not on misunderstandings of the
            criteria, but on legitimate disagreements as to the quality of
            the State's responses.
      --For finalist States, reviewers had three additional opportunities
            to discuss the applications: (1) the panels met to discuss the
            questions they would ask of States during the Q&A session; (2)
            reviewers asked questions of the State to clarify or validate
            their scores and comments; and (3) following the State's
            presentation and Q&A session, the panels met a final time.
        We believe that if, after going through such a rigorous process,
    one of these carefully selected experts believed that an application
    deserved a relatively higher or lower score than other reviewers on the
    panel believed it deserved, that professional opinion should not be
    ignored by the Department. Discounting the diversity in reviewer
    opinions or scores could exclude meaningful information that was the
    product of a thorough review process. To ignore or eliminate such
    information would be counterproductive to our goal of funding the
    highest-quality applications. Please also understand that, even if we
    had thrown out the highest and lowest scores in the phase 1
    competition, Delaware and Tennessee would have still been the two top-
    scoring applications. Thus, taking that step would likely not have
    affected the outcome of the competition.
        Having said that, I agree that we might increase inter-reviewer
    reliability by improving our peer reviewer training. In phase 1 of the
    competition, we had no exemplar applications because the competition
    was brand new--thus, we could not ``anchor'' reviewers' understandings
    in any common activities. Using the information we gained during phase
    1, we plan to expand our reviewer training for phase 2 to include
    workshops in which reviewers read and discuss sample responses,
    practice the ``panel review'' process, and develop a deeper
    understanding of the criteria and scoring rubric. We expect these
    actions to improve the overall quality of both scoring and commenting.
        Finally, we are in the early stages of thinking about the criteria
    for a phase 3 of Race to the Top. We will work hard to ensure that all
    aspects of a phase 3, from the criteria to the reviewer training, are
    deeply informed by what is working, and what is not working as well, in
    Race to the Top and other Department programs.

                      TEACHER AND LEADER PATHWAYS PROGRAM

        Question. In the budget, you have proposed to consolidate a number
    of existing education funding streams into a few competitive programs.
    One program affected by this consolidation of funding streams is Teach
    for America, the national program that recruits outstanding college
    graduates to teach for 2 years in underserved schools. This program has
    been incredibly successful all over the country, particularly in my
    home State of Louisiana where we now have 608 corps members in 148
    schools reaching 38,500 low-income students.
        Right now, because of the enormous increase in applications that
    Teach for America is experiencing, it has the opportunity to double in
    size, but doing so will require a reliable funding stream. The timing
    of the proposed grant competition would not allow Teach for America to
    grow in 2011 or 2012--and they would be forced to reduce the size of
    the incoming corps.
        How do you propose to bridge this funding gap so that Teach for
    America can continue to grow and place effective teachers in the
    schools where they are needed the most during this upcoming school
    year?
        Answer. I share your admiration for the important role that Teach
    for America plays--as well as other alternative pathways to teaching
    programs--in helping high-need districts recruit candidates to teach in
    high-need schools. During the 2008-2009 school year, the last year of
    my tenure in Chicago, 248 Teach for America corps members were teaching
    in the Chicago Public School System and helping to raise the
    achievement and improve the lives of more than 25,000 students. The
    2010 appropriation of $18 million for Teach for America represents an
    increase of more than 20 percent above the funding it received in 2009
    under the Fund for the Improvement of Education. The Department expects
    to receive an application for these funds from Teach for America
    shortly and anticipates that it will be able to award the grant 4 to 6
    weeks later.
        For 2011, the administration has requested $405 million for a new
    Teacher and Leader Pathways program that would allow States and
    districts to create or expand teacher and leader preparation programs,
    including alternative routes to teaching like Teach for America. This
    creates an opportunity for Teach for America and other organizations
    committed to recruiting and supporting exceptional teachers to partner
    with States and districts to compete for significantly more funding
    than is currently available to them under the current system of
    smaller, often narrowly targeted programs. We recognize that a
    significant change like this creates uncertainty, but the
    Administration is committed to working with the Congress, States,
    districts, and other stakeholders, including Teach for America, to
    ensure that the implementation of this new program supports and
    enhances their efforts to improve education.
    Investing in Innovation Program and Support for Teach for America
        Organizations like Teach for America are also eligible to compete
    for funding under the Investing in Innovation program, which supports
    the development and expansion of innovative practices to improve
    student achievement and close achievement gaps. Applications for the
    2010 competition were due on May 12, 2010. The administration has also
    requested $500 million for this program in 2011 to support another
    round of awards for exceptional, innovative programs. In addition,
    States may use funds received under the Race to the Top and under the
    proposed Effective Teachers and Leaders State grants program to support
    Teach for America projects.

                       TEACHER AND LEADER INNOVATION FUND

        Question. The administration's request includes $950 million for
    the new Teacher and Leader Innovation Fund. How does the administration
    plan to encourage these States and LEAs to develop and use innovative
    teacher compensation systems under the proposed Elementary and
    Secondary Act (ESEA) reauthorization?
        Answer. The Teacher and Leader Innovation Fund would provide
    support for State and LEA efforts to develop and implement innovative
    approaches to human capital systems. It would support compensation
    reforms and complementary reforms of teacher and principal development
    and evaluation, teacher placement, and other practices. Grantees,
    selected competitively, would use program funds to reform teacher and
    school leader compensation and career advancement systems, improve the
    use of evaluation results for retention and compensation decisions, and
    implement other innovations to strengthen the workforce.

                             TEACHER INCENTIVE FUND

        Question. How will the Teacher and Leader Innovation Fund work
    should it not be reauthorized?
        Answer. If authorized, the Teacher and Leader Innovation Fund would
    build on the strengths of the Teacher Incentive Fund (TIF). If Congress
    does not reauthorize the ESEA in time to govern the fiscal year 2011
    appropriation, the administration believes its requested increase for
    ESEA programs should be devoted to existing programs best positioned to
    reform K-12 education, such as the TIF, and would seek funding of $800
    million for this program, $400 million more than the fiscal year 2010
    appropriation, for continuation grant costs and approximately 100 new
    awards.

             CHARTER SCHOOLS--EXPANDING EDUCATIONAL OPTIONS PROGRAM

        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 $54 million increase for Charter Schools Grants,
    even if ESEA is not reauthorized this year. Could you talk about how
    the administration plans to address the challenges charter schools face
    in securing facilities funding?
        Answer. The administration is proposing a new program that would
    replace current ESEA programs that support choice-based models of
    school reform as well as family outreach. The Expanding Educational
    Options program would include two separate grant competitions: (1)
    Supporting Effective Charter Schools Grants; and (2) Promoting Public
    School Choice Grants. Under the Supporting Effective Charter Schools
    Grants competition, State educational agencies, charter school
    authorizers, charter support organizations, charter management
    organizations, and other nonprofit organizations in partnership with
    LEAs would be eligible to apply for competitive grants to start or
    expand effective public charter schools and other effective autonomous
    public schools. The Department would work to ensure the creation of
    quality schools by selecting applicants based on their record of
    success in supporting, overseeing, or operating (depending on the type
    of grantee) effective charter and other autonomous schools, including
    their record of closing ineffective charter and other autonomous
    schools, as appropriate, and their commitment to starting schools that
    would expand options for students attending low-performing schools. In
    addition, the Department would give priority to applicants proposing to
    create or expand effective public charter schools.
        As part of this strategy, we believe it is crucial to continue to
    support State and local efforts to ensure that charter schools have
    adequate facilities. We are proposing in reauthorization that, rather
    than renew various separate programs for charter facilities, Congress
    allows a portion of funds (no more than 10 percent) from the Supporting
    Effective Charter Schools Grants program to be used to award grants to
    those programs that most effectively leverage Federal dollars to
    support charter school facilities. This could result in new funding for
    credit enhancement programs as well as other programs that support
    charter school facilities.
    Charter Schools Facilities Programs
        The fiscal year 2010 appropriations act permitted the Department to
    use a total of $23,082,000 (from the appropriation for the Charter
    Schools Program) to continue the State Charter Schools Facilities
    Incentive program and the Credit Enhancement for Charter School
    Facilities program. From that amount, the Department intends to use
    $14,782,000 to make second-year continuation grants under the State
    Charter School Facilities Incentive program and $8,300,000 for Credit
    Enhancement for Charter Facilities program. The Department's proposed
    reauthorization also includes language that would ensure the continued
    funding of Facilities Incentive Grants to States made in fiscal year
    2009 for the remainder of their award period.
        Under the administration's fiscal year 2011 request for the
    Expanding Educational Options program, approximately $298,000,000 would
    be available for new charter schools awards and approximately
    $102,000,000 would be available for the continuation of multi-year
    charter schools awards made before reauthorization. At least
    $14,782,000 of that amount would be available for State Charter School
    Facilities grants and up to $40,000,000 in new awards could be
    available for programs that also support charter school facilities.
                                     ______

                    Questions Submitted by Senator Jack Reed

          LEVERAGING EDUCATIONAL ASSISTANCE PARTNERSHIP (LEAP) PROGRAM

        Question. I have long worked to improve and fund the LEAP program.
    As such, I was disappointed that the President's fiscal year 2011
    budget eliminated funding for LEAP.
        Particularly during this economic downturn, why would the
    administration propose to eliminate critical need-based aid for low-
    income students--a program that leverages millions of dollars in need-
    based grant aid on the State level, and indeed the only program that
    serves to maintain a State role in providing such need-based grant aid?
        While we both are pleased that significant increases to Pell Grants
    were included in the recent student loan reform law, we still have a
    ways to go in meeting the financial need of students. Do you agree that
    we must leverage the ability of States, institutions, businesses, and
    philanthropic organizations to partner together and provide necessary
    aid and support for students and that the Federal Government cannot be
    the only player at the table when it comes to student aid and support?
        Answer. While providing critical need-based aid remains a priority
    to the administration, LEAP funding was not requested for fiscal year
    2011 because it was clear States have committed to sustaining their
    financial support for students. Since its authorization, LEAP has
    helped to increase State participation, both in terms of the number of
    States providing this aid and in the amounts they provide students. For
    example, in academic year 2006-2007, estimated State matching funds
    totaled nearly $1 billion. This is more than $950 million more than the
    level generated by LEAP's dollar-for-dollar match, and far more than
    would be required even under the 2-for-1 match under Special LEAP. This
    suggests a considerable level of State commitment, regardless of
    Federal expenditures, which is not expected to diminish absent LEAP
    program funding. In place of directing funds to LEAP, the
    administration believes in investing these limited resources in other
    need-based aid programs, including increasing the maximum Pell Grant
    award and providing $750 million to encourage greater college access
    through State and community innovation in the College Access Challenge
    Grants program.

                     COLLEGE ACCESS CHALLENGE GRANTS (CACG)

        Question. While you may offer CACG as an alternative source (to
    LEAP), how do you reconcile the fact that providing need-based grant
    aid is just one of many optional activities for State nonprofits in
    CACG and, as such, the Department's report from last year shows that
    only 9 of 50 States used CACG funding for need-based grant aid?
        Answer. While LEAP has been able to supply need-based grant aid
    specifically, CACGs provide more opportunity for participation by
    charitable and philanthropic organizations, as well as State and local
    governments to aid in the CACG work done by a State, including through
    providing financial resources to students. The program includes a match
    requirement of one-third of the cost of the activities which may come
    from philanthropic or other sources, incentivizing increased investment
    and collaboration. The recently passed Student Aid and Fiscal
    Responsibility Act (SAFRA) authorizes additional funds for the CACGs
    program, totaling $150 million per year through fiscal year 2014,
    providing a huge opportunity to develop promising new practices and
    create a data-driven approach for delivering on a college access
    strategy. The legislation also provides for an increased minimum award,
    such that nearly 20 States will see a quadrupling of their grant
    awards. This will allow for both increased State as well as nonprofit
    participation, and gives States more opportunity to be sources of need-
    based grant aid for students.

                                SCHOOL LIBRARIES

        Question. As you know, the Department's own evaluation of the
    Improving Literacy Through School Libraries program, released last
    year, found that it has been successful. For instance, the evaluation,
    which includes a discussion of the research showing the impact of
    improving school libraries on student achievement, found among other
    things that the program has improved the quality of the disadvantaged
    school libraries receiving the grants, as well as increased
    collaboration and coordination among teachers and school librarians on
    curriculum and related matters. Do you think the Federal Government
    should support initiatives that research has shown to be effective?
    And, if so, why does your budget seek to consolidate funding for a
    number of programs shown to be effective by the Department of
    Education's own evaluations, such as the Improving Literacy Through
    School Libraries program?
        Answer. The Department takes the findings of each evaluation
    seriously and believes that we should learn from promising practices
    and try to build on them. However, the evaluation report you mention
    also stated that some or all of the score increase may be associated
    with other school reform efforts. Consequently, the report concluded
    that no definitive statement could be made about the effect of
    participation in the program on reading assessment scores.
        The administration is proposing to consolidate the Improving
    Literacy through School Libraries program in order to make more
    effective use of the funding for literacy. Federal literacy programs
    have historically taken a fragmented approach. The administration
    believes State and local efforts to improve literacy will be more
    coherent and more likely to drive dramatic improvements in student
    achievement if they have a comprehensive pre-K-12 focus. States and
    districts could use funds from this larger, comprehensive program to
    expand school or classroom library services. This could include
    increasing library collections, opening library facilities for longer
    hours, or providing professional development to school librarians.

             GUIDANCE ON USE OF FEDERAL FUNDS TO SUPPORT LIBRARIES

        Question. You have on occasion, including in a letter to me,
    expressed the importance of well-resourced school libraries. Indeed,
    such well-resourced and well-staffed school libraries play an essential
    and vibrant role in amplifying the learning that goes on in classrooms
    and providing students with the critical thinking skills to evaluate
    and use information and ultimately gain knowledge. As such, did you
    provide any specific guidance to schools regarding using ARRA or ESEA
    funding to support school libraries and school librarians?
        Answer. In September 2009, the Department issued guidance entitled
    using title I, part A ARRA Funds for Grants to Local Educational
    Agencies to Strengthen Education, Drive Reform, and Improve Results for
    Students, which included information on how title I ARRA funds could be
    used to strengthen school libraries. This guidance specifies that ``In
    a Title I school operating a school wide program, Title I, Part A ARRA
    funds may be used to purchase library books if using the funds for that
    purpose is consistent with needs identified in the comprehensive needs
    assessment and articulated in the school wide plan.'' It goes on to
    provide clarification about how local educational agencies (LEAs)
    should first leverage State and local resources and about schools
    operating a targeted assistance program. This guidance document also
    states that expanding title I reading and mathematics resources and
    libraries may be an activity that LEAs can carry out in meeting the
    requirement to provide equitable services to private school students.

               EFFECTIVE TEACHING AND LEARNING: LITERACY PROGRAM

        Question. How do you propose ensuring that investments in school
    libraries are made when evidence suggests that (1) libraries are among
    the first items cut from cash-strapped school budgets and (2) in the
    absence of a specific Federal investment, school libraries have
    languished, such as what occurred when the school library program
    included in the original ESEA was eliminated during the Reagan
    administration?
        Answer. The Effective Teaching and Learning: Literacy program would
    provide competitive State literacy grants to State educational agencies
    (SEAs), or SEAs in partnership with appropriate outside entities, in
    order to support State and local efforts aimed at implementing and
    supporting a comprehensive literacy strategy that provides high-quality
    literacy instruction and support to students. Local educational
    agencies could use their grant funds to expand their library
    collections, open their school libraries for longer hours, or provide
    professional development to school librarians. We believe that this
    would be the best approach to ensuring that school libraries and
    library services are supported as part of a comprehensive approach to
    improving student literacy.

                       TEACHER QUALITY PARTNERSHIP GRANTS

        Question. Last Congress, I helped author provisions in title II of
    the Higher Education Opportunity Act--the Teacher Quality Partnership
    Grants (TQP) program--to reform college teacher preparation programs,
    where more than 85 percent of new teachers are prepared each year. The
    final bill that included these provisions had overwhelming support--it
    passed the Senate 83-8 and the House 380-49. Congress spent more than 5
    years deliberatively crafting this program on a bipartisan and
    bicameral basis leading up to the reauthorization in 2008. The majority
    of the first grants through this program were just awarded earlier this
    month.
        Yet the administration has proposed to eliminate this program even
    though there has been no opportunity to prove its effectiveness. We
    have heard for many years that college teacher preparation programs
    need to be reformed. However, by consolidating TQP with a number of
    non-college-based teacher certification programs, there will be no
    guarantee that college teacher preparation programs receive funding to
    actually undertake the reform we both acknowledge needs to occur.
        How will eliminating the one guaranteed Federal source of funding
    for college teacher preparation programs help reform them in any
    systematic way?
        Answer. I see the administration's proposal to consolidate smaller,
    narrowly targeted programs into a Teacher and Leader Pathways program
    in which institutions of higher education would partner with States and
    districts to compete for funding as a natural extension of the teacher
    preparation reforms enacted in the Higher Education Opportunity Act.
    Under the Teacher Quality Partnership Grant program, institutions of
    higher education, in partnership with high-need districts and schools,
    compete for grants to support model teacher preparation programs that
    are accountable for recruiting highly qualified candidates, including
    minorities and individuals from other occupations, and training them to
    be highly qualified teachers who are prepared to meet the needs of
    high-need schools and districts. In 2009, we awarded $43 million in 28
    grants to support pre-baccalaureate and/or teacher residency programs,
    with $100 million in ARRA funds awarded in 2010 to support 12
    additional grants. The 2011 request for the Teacher and Leader Pathways
    program would provide $405 million to significantly expand the amount
    of funding available to States and districts to enable them to partner
    with college-based teacher preparation programs and other organizations
    to compete for funding to develop or expand efforts to recruit, train,
    and support teachers to teach in high-need schools or high-need
    subjects.

                   STRENGTHENING TEACHER PREPARATION PROGRAMS

        Question. Doesn't the need for reform bolster the case instead for
    dedicated resources to strengthen these programs, from which 85-90
    percent of teachers enter the field?
        Answer. In speeches at the Curry School of Education at the
    University of Virginia and Teachers College at Columbia University, I
    have stressed the important role that colleges of education play in
    preparing the vast majority of individuals who become teachers and
    challenged them to reform their programs to make them accountable for
    producing teachers across subject areas who are prepared to help all
    students, regardless of race, national origin, disability, or ZIP code
    to reach their full potential. As teachers in the baby boom generation
    begin to retire, districts will need even more highly effective
    teachers from both traditional colleges of education and alternative
    routes to teaching. Any qualified organization or institution that is
    willing to partner with States and districts and be held accountable
    for preparing teachers who are able to increase student achievement and
    close achievement gaps should be able to compete for scarce Federal
    resources. Our proposed Teacher and Leader Pathways program is flexible
    about the path through which teachers are prepared but firm about the
    results which grantees will be held accountable for producing.

                      TEACHER AND LEADER PATHWAYS PROGRAM

        Question. Why propose to eliminate a program before its
    effectiveness has even been tested?
        Answer. The administration's 2011 request for the Teacher and
    Leader Pathways program included $57 million to continue support for
    the 28 grants that were awarded in 2009. As I mentioned in response to
    an earlier question, the administration's budget request would not
    eliminate funding for partnerships between institutions of higher
    education and districts to improve the quality of teacher preparation
    programs. Instead, it would consolidate these and other program
    authorities to create a larger pool of funds for which States and
    districts could compete for resources to support a broad range of
    activities and approaches tailored to the needs of their communities.

                EVALUATION OF TEACHER QUALITY PARTNERSHIP GRANTS

        The Department is committed to investing in rigorous research and
    evaluation on the effectiveness of various approaches to improving
    teacher quality. In 2010, the Institute of Education Sciences awarded a
    contract for an evaluation of the effectiveness of the teacher
    residency projects supported through the Teacher Quality Partnership
    Grant program, including 12 grants awarded in 2009 and 7 grants awarded
    in 2010 with funds appropriated under the ARRA. The results of this
    evaluation will help States and districts make informed decisions,
    while also providing valuable information to institutions of higher
    education and other teacher residency programs to help them refine and
    enhance their programs.

                              TEACHER PREPARATION

        Question. Do you agree that teacher preparation programs should
    have rigorous clinical experiences, comprehensive induction and
    mentoring, and be closely partnered and aligned with local school
    districts?
        Answer. Recent research suggests that pathways into teaching are
    more effective when they focus on the classroom and provide
    opportunities for teachers to study what they will be doing as first-
    year teachers. For example, teachers who came from programs in which
    they engaged in actual teaching practices, or engaged in a ``capstone
    project''--often resulting in a portfolio of work produced in K-12
    classrooms during the pre-service education component--were more likely
    to produce positive student achievement gains during their first year
    of teaching than were teachers who did not engage in these learning
    experiences. Under the administration's reauthorization proposal,
    individuals participating in the proposed Teacher Pathway program would
    receive intensive clinical experience and induction support, including
    high-quality mentoring. In addition, the Teacher Pathways program would
    support teacher preparation activities that are aligned with the needs
    of local communities.
                                     ______

                   Questions Submitted by Senator Mark Pryor

                            SCHOOL TURNAROUND GRANTS

        Question. The Department's fiscal year 2011 budget request proposes
    $900 million for a reauthorized School Turnaround Grants program
    intended to help States and local education agencies ``turn around''
    the country's 5,000 lowest performing schools over the next 5 years.
    The Department's Blueprint for Elementary and Secondary Education Act
    reauthorization outlines four models including a school closure model,
    a restart model, a turnaround model, and a ``transformation model'' in
    which the principal is replaced, staff are strengthened, and extended
    learning time is provided, among other reforms. For rural areas, these
    models pose a challenge. I'm concerned that some of the proposed
    reforms may not be optimal for Arkansas--especially with respect to
    laying off one-half of the school staff or shutting down the school and
    reopening it.
        Mr. Secretary, how will you ensure rural districts have flexibility
    in school improvement through the proposed four models under the school
    turnaround grants program you have proposed?
        Answer. We recognize that rural school districts face unique
    challenges and require flexibility to develop and implement effective
    plans for turning around their persistently lowest-achieving schools.
    In particular, some rural schools may have difficulty providing access
    to a well-rounded education, recruiting and retaining effective
    teachers, and serving high concentrations of poor students. At the same
    time, we know that all children can learn with the appropriate support,
    and the School Turnaround Grant program was designed to help all
    districts and schools, including those in rural areas, provide that
    support. The transformation model, in particular, was developed with
    input from stakeholders from rural communities, to make sure that these
    communities have the ability to turn around their struggling schools.
    This model gives rural districts an option that can work for them and
    that can deliver dramatic change students need.

                             PROGRAM CONSOLIDATIONS

        Question. In the Department's budget proposal, many K-12 programs
    are consolidated into fewer, broader programs aimed at meeting targeted
    goals. Arkansans have benefited from several worthy programs, such as
    Teach for America, Javits, and Literacy Through School Libraries, that
    have been consolidated.
        How will these larger programs meet the needs many of the smaller
    programs targeted?
        Answer. In most cases, the larger, consolidated programs we are
    proposing through reauthorization are flexible enough to continue
    supporting high-quality projects that carry out activities in the
    specific areas you mention. Our goal in consolidating multiple current
    authorities is not to eliminate support for worthy reforms and
    activities, but to focus effort in a few critical areas, build an
    evidence base of what works through rigorous program evaluations, and
    help us lead the field by directing funding and attention to scaling up
    the best ideas.
        Question. How do you envision funding should be structured to meet
    the overall goals of these consolidated programs?
        Answer. The President's budget includes a proposed structure for
    funding activities within broader, more comprehensive authorities
    contained in our reauthorization plan. We believe these broader
    authorities will provide States and districts the flexibility to focus
    on their specific needs, enable the Department to build an evidence
    base of what works through rigorous program evaluations, and help us
    lead the field by directing funding and attention to scaling up the
    best ideas.
                                     ______

                  Questions Submitted by Senator Thad Cochran

           PROGRAM CONSOLIDATION PROPOSAL AND PROSPECTIVE APPLICANTS

        Question. The Department of Education's fiscal year 2011 budget
    proposes authorizing legislation which would consolidate a number of
    existing programs, including the National Writing Project, into 11 new
    programs. Under your consolidation proposal, could you identify the
    types of organizations that you anticipate will compete for grants,
    including organizations that receive grants under the existing
    programs?
        Answer. The eligible entities will vary by program and it is
    difficult to speculate which organizations might choose to apply for
    competitions that have not yet been announced. An organization such as
    the National Writing Project would be encouraged to partner with States
    or districts in order to further the implementation of comprehensive
    literacy plans under the Effective Teaching and Learning: Literacy
    program.

                            NATIONAL WRITING PROJECT

        Question. As the Department of Education's budget appears to direct
    funding to States and localities, how would national nonprofit
    organizations, such as the National Writing Project, be able to compete
    for funding?
        Answer. Eligible entities vary by program. National nonprofit
    organizations would still be eligible for funding in programs such as
    Investing in Innovation and national activities competitions within
    Effective Teaching and Learning for a Complete Education. The National
    Writing Project could participate in these competitions or partner with
    States and districts in order to further the implementation of
    comprehensive literacy plans.

                              GEOGRAPHIC EDUCATION

        Question. As geographic literacy will be critical for our Nation's
    students to compete in a global economy, does the Department of
    Education's fiscal year 2011 budget proposal to create a new Effective
    Teaching and Learning for a Well-Rounded Education program do enough to
    ensure that funding is committed to geographic education activities?
        Answer. The administration agrees that geography is an important
    subject that our students should study as part of a complete education.
    Our proposal for Effective Teaching and Learning for a Well-Rounded
    Education would provide support for geography, as well as other
    subjects, through the identification, development, implementation, and
    replication of evidence-based programs, strategies, and practices.
    Under the current ESEA, geography is listed as one of the core academic
    subjects but ESEA funding has not been used to strengthen geography
    education unless States or districts have elected to use some of their
    formula funds for that purpose. By making geography one of the subjects
    that could be supported directly with grants from the Effective
    Teaching for a Well-Rounded Education program, we believe that our
    proposal would make geography a more prominent focus in the
    reauthorized law and make it more likely that projects supporting
    geography education will be funded.
        Question. What assurances can the Department of Education make to
    ensure that under this new program funding would be directed to
    geographic literacy activities?
        Answer. Under our reauthorization proposal, the Department could
    designate specific subjects to be supported in a particular year, or
    could hold a broad competition through which eligible entities could
    apply to carry out projects in any of the subjects covered by the
    program (the arts, foreign languages, civics and government, geography,
    environmental education, and economics and financial literacy). The
    Department could also support interdisciplinary projects cutting across
    a number of those projects. The amount of funding used to support
    geography would depend on the amount of the annual appropriation, the
    requirements and priorities announced by the Department, and the
    quality of applications received.

                         CAREER AND TECHNICAL EDUCATION

        Question. The Carl D. Perkins Career and Technical Education Act is
    the primary program in the Department of Education that supports
    preparing students for their future careers, a key element of the new
    focus on college and career readiness. What role do you see career and
    technical education playing in helping students become career and
    college ready?
        Answer. Career and Technical Education (CTE) programs represent one
    of the many pathways available to students to help them become college
    and career ready. These programs provide instruction that integrates
    both academic rigor and career and technical skills. In addition, the
    statutory requirement that States offer ``programs of study'' should
    enhance the capacity of CTE programs to prepare students for career and
    college. Programs of study are coherent sequences of nonduplicative CTE
    courses that progress from the secondary to the postsecondary level,
    include rigorous and challenging academic content along with career and
    technical content, and lead to an industry-recognized credential or
    certificate at the postsecondary level or to an associate or
    baccalaureate degree. They may also incorporate a dual-enrollment
    component, where a student takes postsecondary coursework while still
    in high school and accrues postsecondary credits while doing so. High
    school students who have completed programs of study are not only
    likely to graduate college and career ready, but they also have already
    taken foundational courses in a specific career area and are ready for
    more advanced coursework at the postsecondary level in the same career
    area.

            REACH OF CTE PROGRAMS AND STEPS TO IMPROVE CTE PROGRAMS

        Question. How can programs continue to expand and improve to serve
    more students under the Department of Education's fiscal year 2011
    budget proposal?
        Answer. Career and technical education programs already serve most
    high school students in this country. According to an April 2009
    National Center for Education Statistics report, 97 percent of all 2005
    public high school graduates had earned CTE credits. In terms of
    improving programs, the requirement that States offer programs of study
    as part of their CTE programs holds great promise. State and local
    recipients of Perkins funds must create at least one program of study
    for their students. A program of study must be specific to a career
    field and integrate academic and technical content in a coherent
    manner. It must also clearly specify the progression of coursework a
    student should follow at the secondary level and the coursework a
    student would pursue at the postsecondary level to eventually attain a
    credential or degree in that career area. In addition, the courses must
    not be duplicative. Thus, this approach should not only ensure that CTE
    students are attaining both academic and technical content, but that
    they do not need to repeat coursework during their postsecondary
    studies. In addition, it lets students know exactly what they need to
    do attain a credential, certificate, or degree in a specific area. The
    Department has provided guidance and technical assistance to States in
    order to help them develop rigorous high-quality programs of study.

                    21ST CENTURY COMMUNITY LEARNING CENTERS

        Question. How would the process of awarding grants occur under the
    Department of Education's fiscal year 2011 budget proposal to make 21st
    Century Community Learning Centers (21stCCLC) grants competitive?
        Answer. As for any other competitive grant competition, the
    Department would set evaluation criteria and prepare application
    requirements and criteria to which eligible entities would have to
    respond to be considered for a grant. Assuming that the fiscal year
    2011 appropriation for the 21st CCLC program adopts the
    administration's proposal and continues to be multiyear funds, the 21st
    CCLC grants would be competitively awarded to States during fiscal year
    2012.
        Question. How many States do you anticipate would receive 21stCCLC
    awards in fiscal year 2011?
        Answer. The Department has not established an estimated number of
    awards. We would fund as many high-quality applications as possible
    with the amount Congress appropriates for the program.
        Question. As under the current 21stCCLC formula grant structure
    where all States are guaranteed to receive a share of funding, will
    small States, such as Mississippi, be able to effectively compete
    against large States for these awards?
        Answer. Our experience indicates that small States can be as
    competitive as the larger States. For instance, most recently in the
    Race to the Top Phase 1 competition, one very small State (Delaware)
    and one medium-size State (Tennessee) were the two winners.
        Question. How would States that do not receive a competitive award
    under this restructured program make up for the loss in Federal funding
    for the 21stCCLC?
        Answer. States that do not receive 21stCCLC could consider ways
    that State funds and other Federal funding streams, such as title I or
    the Child Care Development Block Grant, can be used for activities that
    were supported by the 21st CCLC program. We would also strongly
    encourage States take steps to enable them to submit a high-quality
    application for a grant in future years.

                    PUBLIC TELEVISION CHILDREN'S PROGRAMMING

        Question. The Department of Education's fiscal year 2011 budget
    proposes to consolidate funding for Ready To Learn (RTL), a program
    with a nearly 20-year proven record of using the power and reach of
    public television's children's programming to better prepare young
    children for success in school. This new ``Effective Teachers and
    Learning: Literacy program,'' would appear to make direct RTL funding
    unavailable to public broadcasting and would negatively impact national
    distribution. At the same time, the Department has put out a Request
    for Proposals (RFP) for the program's fiscal year 2010 funding that
    calls for ``transmedia storytelling'' projects, rather than television-
    focused projects. What assurances can you give that the Department will
    continue its nearly 20-year partnership with public television?
        Answer. From the amount requested for the Effective Teaching and
    Learning for a Complete Education programs, the administration would
    reserve funds to support a range of national activities. Public
    telecommunications entities--such as the Public Broadcasting Service
    (PBS) and the Corporation for Public Broadcasting (CPB)--would be
    encouraged to compete for such national activities funding to create
    high-quality, educational content for children. It is important to
    recognize that even if neither PBS nor CPB were to submit a winning
    application in response to the 2010 competition, the Department's
    partnership with public television would still remain healthy because
    the majority of funds available to support this activity would very
    likely end up going to support applications from one or more of the
    many PBS-affiliate stations, which currently develop and produce much
    of the original children's educational programming content that is
    distributed over public television.

                                 READY TO LEARN

        Question. Will Ready to Learn have the same impact, reach and
    success if carriage on television is phased-out or minimized?
        Answer. The Department envisions that the impact, reach, and
    success of Ready to Learn could be augmented by taking steps to ensure
    that high-quality, educational programming content not only reaches and
    benefits the widest audience possible, but also to ensure that such
    materials are coordinated across a variety of media distribution
    platforms, including television. The Department does not envision that
    ``carriage'' or distribution of children's educational programming
    content using television will be phased-out or minimized. Instead, in
    the Request for Proposals published in March 22, 2010, the Department
    ``encourages applicants to deliver early learning content through the
    well-planned and coordinated use of multiple media platforms.'' This
    well-planned and coordinated use of platforms necessarily includes
    television--but we believe that the potential educational benefits of
    children's programming content can be greatly enhanced if television is
    not relied on as the sole distribution mechanism.

                         EARLY LEARNING CHALLENGE FUND

        Question. The Department of Education's fiscal year 2011 budget
    proposal does not request funds for a new Early Learning Challenge Fund
    since it was assumed that funding would be enacted and funded as part
    of the budget reconciliation act. Since funding did not come to bear in
    reconciliation, what are your plans for funding the Early Learning
    Challenge Fund?
        Answer. Early learning remains a priority for the administration
    and we are considering ways that we can work with Congress to provide
    funds for the Early Learning Challenge Fund.

          INCORPORATING EARLY LEARNING INTO FEDERAL EDUCATION PROGRAMS

        Question. How do you intend to incorporate early learning into
    existing program authorities?
        Answer. Early learning is a high priority for the Department. We
    are encouraging States and LEAs to use ESEA title I, part A funds to
    support high-quality early learning programs, and are continuing to
    support early learning services for students with disabilities through
    the IDEA parts B and C. We also will be working with States to
    implement the Striving Readers program; at least $32 million of the
    $250 million fiscal year 2010 appropriation for that program will be
    used to serve children from birth through age 5. In addition, $10
    million will be used to provide formula grants to States for the
    establishment or support of a State Literacy Team with expertise in
    literacy development and education for children from birth through
    grade 12.
        It is also important to note that we are incorporating early
    learning into our reauthorization proposal for the ESEA. For example,
    the proposed Academic Excellence in Core Subjects programs would
    support State and local efforts to implement high-quality instruction
    in literacy, science, technology, engineering, and mathematics, and
    other subjects that are part of a well-rounded education. The Excellent
    Instructional Teams programs would also improve early learning programs
    by allowing the use of program funds to support teachers and leaders
    who serve children before kindergarten entry.

                             EDUCATIONAL TECHNOLOGY

        Question. The Department of Education's fiscal year 2011 budget
    proposal would eliminate the Enhancing Education Through Technology
    Program. While the budget proposal states that technology will be
    infused throughout programs, a State grant program that specifically
    provides funds for helping schools upgrade their technology needs and
    to integrate technology into instruction would not receive funding. How
    would the Department of Education's fiscal year 2011 budget proposal
    ensure that funding is provided for these activities?
        Answer. The administration proposes to support the integrated use
    of technology through the Effective Teaching and Learning for a
    Complete Education programs. The proposed new programs will include (1)
    Effective Teaching and Learning: Literacy; (2) Effective Teaching and
    Learning: Science, Technology, Engineering, and Mathematics (STEM); and
    (3) Effective Teaching and Learning for a Well-Rounded Education. For
    these three new programs, applicants that propose to use technology to
    address student learning challenges will be given priority.
        The Department's fiscal year 2011 budget request includes $300
    million for STEM education grants to be awarded on a competitive basis.
    Grantees will be required to use its funds to carry out activities to
    improve teaching and learning in mathematics or science and may also
    carry out activities to improve teaching and learning in technology or
    engineering.
        In addition, the Department plans to emphasize using technology to
    drive improvements in educational quality through the reauthorized
    Investing in Innovation program. Under that proposal, the Secretary
    would be authorized to designate support for the effective use of
    education technology to improve teaching and learning as one of the
    priorities that applicants may address in their applications for
    competitive awards.

                 REPLICATING PROMISING PRACTICES AND STRATEGIES

        Question. The Department of Education's fiscal year 2011 budget
    proposal places a strong emphasis on identifying promising practices
    and strategies that can be replicated in classrooms, schools, and
    districts. What will the Department of Education do to capture and
    disseminate this knowledge so educators and administrators across the
    country can use promising practices to improve classroom instruction,
    school leadership, academic performance for all students, and close
    historic achievement gaps?
        Answer. The Department employs a wide range of grant and contract
    vehicles to ensure that classroom educators, school leaders, and State
    and district policymakers have the information they need to select
    promising practices and strategies that meet the needs of their
    students. Through the What Works Clearinghouse and the Education
    Resources Information Center, the Institute of Education Sciences makes
    research and evaluation studies available to both the research and
    practitioner communities in clear, concise formats that provide
    methodological and technical information on the strength of the
    evidence to support claims of effectiveness. The Department's technical
    assistance providers, including the Regional Educational Laboratories,
    the Comprehensive Centers, the Parental Information and Resource
    Centers, the Equity Assistance Centers, and Parent Information Centers,
    work with States, districts, schools, and parents to translate research
    and evaluation findings into practical strategies to improve student
    achievement. In addition, through the Technical Assistance and
    Dissemination program, the Office of Special Education Programs
    supports a network of grants providing technical assistance,
    dissemination, and model demonstration activities on a range of issues
    related to improving the education of students with disabilities. The
    Department is working to develop a comprehensive strategy that will
    leverage technical assistance and dissemination resources across
    programs and offices to coordinate the provision of services and foster
    the sharing of best practices and research information across programs
    and topic areas.

                              SUBCOMMITTEE RECESS

        Senator Harkin. Thank you very, very much. Thank you all.
        [Whereupon, at 11:17 a.m., Wednesday, April 14, 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 2011

                                  ----------

                             WEDNESDAY, MAY 5, 2010

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 9:35 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tom Harkin (chairman) presiding.
        Present: Senators Harkin, Pryor, Specter, and Cochran.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF FRANCIS S. COLLINS, M.D., Ph.D., DIRECTOR,
                NATIONAL INSTITUTES OF HEALTH

                    OPENING STATEMENT OF SENATOR TOM HARKIN

        Senator Harkin. The Senate Subcommittee on Labor, Health,
    Human Services, and Education, and Related Agencies
    appropriations will come to order.
        I want to start, first, by welcoming Dr. Francis S.
    Collins, who, of course, has appeared before this subcommittee
    many times over the past 20 years. Until now, he always
    testified as the Director of the National Human Genome Research
    Institute (NHGRI), today, wearing a much different and bigger
    hat, as Director of the entire National Institutes of Health
    (NIH).
        The fiscal year 2010 budget for the NHGRI is $516 million.
    The budget for NIH as a whole is $31 billion. Well, at least
    that's where it is right now, anyway; we're looking at that.
    And, of course, the portfolio as NIH Director is much larger
    than the one that Dr. Collins had at the NHGRI.
        But, having known Dr. Collins for all these years, I can't
    tell you how proud I am, and honored, that he is, now, the
    Director of the NIH.
        I can remember when you first took over at the Genome
    Project--I think it was called a ``project'' at that time--
    1992? 1993? I knew I was close, Dr. Collins. I was close. And
    to take the project to the complete mapping and sequencing of
    the human genome was a singular accomplishment. And as I said,
    watching you during that whole time, and watching you shepherd
    that thing through, I'm telling you, you're in the right place
    at the right time, right now, as Director of NIH.
        One of the things that--when you think about the issues
    that confront NIH today--what role does biomedical research
    play in healthcare reform? How can we capitalize on the Human
    Genome Project that we completed? How can we do a better job of
    translating basic research in the field? How can we encourage
    some of our brightest young minds to enter this field when
    we've got tight budgets? So, we need someone who thinks big to
    head up NIH, and that's why we have Dr. Collins here, because
    he does think big, and he accomplishes big things.
        So, the President's budget for the NIH for 2011 calls for a
    $1 billion increase more than the 2010 level, a total of $32
    billion; it's about a 3.2 percent increase, which I am told is
    the same as the biomedical inflation rate.
        But, fiscal year 2011 will bring with it a very special set
    of challenges; namely, how to achieve the softest possible
    landing for NIH after the $10.4 billion that was appropriated
    in the American Recovery and Reinvestment Act (ARRA). That is
    one area that I hope to explore with Dr. Collins in our
    question-and-answer period.
        I also want to spend some time discussing one of the
    questions I raised earlier, how we can more effectively
    translate basic science into treatments and practices that
    actually improve people's health.
        I know you've heard me say this many times before, Dr.
    Collins, that there's a reason it's called the National
    Institutes of Health, not the National Institutes of Basic
    Research.
        But, before we hear from Dr. Collins, I would yield to
    Senator Cochran for his opening statement.

                       STATEMENT OF SENATOR THAD COCHRAN

        Senator Cochran. Mr. Chairman, thank you very much for
    conducting this hearing, looking at the budget requests for the
    next fiscal year for the Department; that is, the NIH;
    specifically, under the generalship of Dr. Collins.
        We appreciate very much your fine leadership and good work
    not only as a researcher, but also to manage and help identify
    priorities that help this subcommittee decide how much funding
    we need to place in the different accounts in this bill. It's a
    very large bill. We wish it could be larger, but the budget
    constrains us. But, within that budget framework, we have to
    identify the highest priorities, and your testimony will help
    us do a better job of that. And so, we appreciate your
    assistance to the subcommittee and your leadership in your
    role.
        Thank you.
        Senator Harkin. Thank you, Senator Cochran.
        I didn't read that before I sat down, I just thought
    ``turning discovery into health.'' That's one of the things I
    wanted to talk about.
        [The information follows:]

        www.nih.gov/about/discovery

        Senator Harkin. Well, Francis S. Collins, M.D., Ph.D., was
    sworn in as the 16th Director of the NIH in August 2009, after
    being unanimously confirmed by the Senate. A physician-
    geneticist noted for his discoveries of diseased genes, his
    leadership of the Human Genome Project. Prior to becoming NIH
    Director, he served as the Director of the NHGRI at NIH. He
    received his B.S. from the University of Virginia, Ph.D. from
    Yale, and an M.D. from the University of North Carolina at
    Chapel Hill.
        Well, Dr. Collins, welcome. You're no stranger to this
    subcommittee. Your statement will be made a part of this record
    in its entirety, and you can please proceed as you so desire.

                    SUMMARY STATEMENT OF FRANCIS S. COLLINS

        Dr. Collins. Well, thank you, Senator. And it is a great
    pleasure to be here. Good morning to all of you. It's an honor
    to appear to present the NIH's budget request for fiscal 2010
    and to discuss my vision for the future of biomedical research.
        I'd like for my written testimony to be included in the
    record, and I'm going to deviate from it quite a bit this
    morning in this opening set of remarks.
        First of all, I'd certainly like to thank all of you for
    your steadfast support of NIH's mission: to discover
    fundamental knowledge about the nature and behavior of living
    systems, but then to apply that knowledge to fight illness and
    to reduce the burdens of disability. And this is--of course, we
    are the National Institutes of Health--I think I've quoted you
    on that, actually, Senator Harkin--not the National Institute
    of Basic Science. We are passionate about taking the
    discoveries that are pouring out of research laboratories, and
    moving them quickly toward clinical benefits.
        Over the course of 15 years as Director of the NHGRI, I
    must say I was grateful for this subcommittee's strong support.
    Even at a time, early on, when the scientific community was
    somewhat divided about whether the Genome Project was worth
    investing in, this subcommittee was a strong supporter. And
    you, particularly, Mr. Chairman, were a vocal and articulate
    visionary for what this project might do. And your vision has
    been coming true ever since. And I--I'm personally grateful to
    you for that leadership.
        So, I want to introduce you today, instead of going through
    some specific scientific advances, to some people.
        Let's begin with Kate Robbins. Eight years ago, at the age
    of 44, this nonsmoking mother of two, was diagnosed with lung
    cancer; specifically, non-small-cell lung cancer. It had
    already metastasized to her brain. Normally this would be a
    death sentence. Despite surgery, radiation, chemotherapy, the
    cancer continued its deadly march, moving into her liver, into
    her pancreas. Still, she kept on fighting. And in early 2003,
    she enrolled in a trial of a drug called gefitinib, which is
    trade name Iressa, which is a new genome-based drug for cancer,
    based on a molecular understanding of what has gone wrong in
    certain cases of lung cancer.
        Now, after she started the drug, most of her metastases
    vanished. Look at these CT-scans. This was her original one. In
    2002, all of those dark areas are cancer in her liver. Just 6
    months later, all but one is gone. And today there is no
    evidence of cancer in her liver, at all.
        Now, why doesn't this work in all cases? In her case, a
    miraculous recovery. She's 7\1/2\ years out, with no sign of
    cancer in her liver or her lungs or her pancreas.
        The disappointing news is that this drug only works in
    about one-fifth of lung cancer patients. But, we now know why.
    If your tumor has a specific mutation in a gene called EGFR,
    this drug is for you. If your tumor does not have that
    mutation, this drug probably will not work. So, this
    demonstrates the potential of personalized medicine, which is a
    major frontier right now for cancer, for heart disease, for
    virtually all conditions; that we can individualize treatment
    instead of doing the one-size-fits-all approach.
        Well, next I'd like you to meet 9-year-old Corey Haas. This
    is Corey and his mom and dad. Corey was affected by a disease
    that was robbing him of his vision, a disease called Leber's
    congenital amaurosis, which is quite a mouthful, but it leads
    to progressive vision loss. And by age 7, Corey was legally
    blind. But, he underwent, in an experimental procedure
    supported by NIH at the University of Pennsylvania, a gene-
    therapy approach. Basically, the idea here was to take a normal
    copy of RPE65 and inject it, in a viral vector, into the back
    of his eye. And let me show you what happened, in the videos
    that you can see.
        One eye was treated, and then, by patching one eye and
    looking to see how he would do in being able to follow some
    arrows on the floor, you can see what the effects were.
        So, let's start here. Now, at this point, his treated eye
    has been blocked, so you're seeing what he's able to see
    without treatment, trying to follow these little arrows on the
    floor. And he's basically being asked to follow them, he's
    saying, ``I can't see them.'' He's frustrated; he's standing
    there, he really can't see where anything is. They're asking,
    ``Do you want a clue?'' He finally says, ``I can't see
    anything.''
        Now, same day, they now patch the untreated eye so he can
    see with the eye that's received the gene therapy. And watch
    what happens. ``Okay, follow those arrows, Corey.'' No
    mistakes. He even had to climb over an obstacle, there, and go
    all the way around. And he decided he was doing so well, he
    wouldn't even stop, he'd just walk outside the door.
        And if we had the audio, you would have heard wild applause
    from the researchers, at that point.
        So, isn't that dramatic? And this has been, in Corey,
    sustained for more than a year, and now the consideration is to
    treat the other eye.
        A third story. This is one that features prevention-
    oriented research. Now this is about Leslie Cook. She smoked
    for 25 years, half of her life, a habit that put her at
    increased risk for heart attack, cancer, and many other
    diseases. She's a high-powered real estate lawyer; she tried to
    kick the habit many times. She tried the gum, the patch, you
    name it; nothing worked for her.
        And then she enrolled in a phase II trial of a vaccine
    against nicotine, called NicVAX. The vaccine spurs the immune
    system to generate antibodies against nicotine. Those bind to
    it, preventing it from entering the brain, and therefore no
    pleasure response occurs after smoking. NicVAX did the trick
    for Leslie; she has not smoked in 3\1/2\ years.
        And there is now a phase III trial underway here, supported
    by the ARRA, to test this in 1,000 smokers at 20 centers. It's
    the first-ever phase III trial of a smoking cessation vaccine.
        So, thanks to the discoveries you have funded----
        Senator Harkin. Working on a broad basis? Now, this is not
    personalized, it doesn't depend on a certain gene, or----
        Dr. Collins. No. In this case, the vaccine is actually
    raised against the nicotine itself, so the antibodies are
    against the material in the cigarette smoke that gives people a
    high, and it blocks that effect, and so there's no point in
    smoking and they have an easier time quitting. It's pretty
    dramatic. That has not, I think, previously been tried for this
    purpose.
        So, we're mixing immunology and drug addiction in
    interesting ways. There are efforts underway to do this, also,
    for other drugs of addiction.
        Well, let me quickly conclude, here, by just quickly
    pointing out to you that these represent just a few of the
    exciting areas of opportunity. When I first came to this job--
    and it is an incredible responsibility, of leading the NIH--I
    scanned the landscape a bit, of biomedical research, to
    identify areas that seemed ripe for major advances and, in the
    process of doing so, identified five themes that I thought were
    particularly ripe for investment. And you have in front of you
    this publication from Science, published in January, that goes
    through a description of those five themes, and I think that's
    been reasonably well received by the scientific community.
        One of them is to use the high-throughput technologies that
    have been invented in the last few years--genomics,
    nanotechnology, imaging, computational biology--to really
    tackle questions in a comprehensive way; questions like the
    causes of cancer or autism or what role microbes play in
    disease when we can't actually culture them in the laboratory
    but we can detect their presence by DNA analysis.
        A second opportunity, and one that you've mentioned
    already, Mr. Chairman, the importance of translating the basic
    science discoveries into new and better treatments, of building
    a bridge, as you see done here for San Francisco, but a bridge
    between basic research and drugs and empowering academic
    investigators to play a larger role in that. And the Cures
    Acceleration Network (CAN), which is part of the healthcare
    reform bill, is an important aspect of this that we're very
    excited about.
        I should also say, stem cells fit into here, and I'm happy
    to tell you there are now 64 human embryonic stem cell lines
    that are on the NIH registry and approved for Federal funding,
    followed up on Obama's Executive order from a year ago.
        A third area, represented by these banners here, is to
    reach out with NIH research results and actually have an effect
    on our healthcare system. And that means personalized medicine
    research, health disparities research, comparative
    effectiveness research, behavioral research, and even
    healthcare economics. We're having a major meeting on that next
    week.
        A fourth area is to recognize that we have both
    opportunities and perhaps responsibilities to apply our medical
    research efforts to those in less fortunate parts of the world,
    and that means a focus on AIDS, tuberculosis, and malaria, but,
    going beyond that, to neglected tropical diseases and
    noncommunicable disorders, which are the most rapidly growing
    cause of morbidity and mortality in the developing world.
        And finally, the reinvigoration and empowerment of the
    research community, which is a challenge, especially at times
    of stressed budgets, to be sure that we're encouraging young
    investigators, that we're encouraging innovation, that we're
    training the next generation, using the Ruth Kirschstein
    awards. And I should, for a moment here, just say how much we
    miss Dr. Kirschstein, such a remarkable leader of NIH. We're
    having a special symposium in her honor, later this month,
    bringing back many of the people who were supported by those
    Kirschstein awards, in recognition of the role she's played in
    so much of what we've done in training.
        Also in front of you is this pamphlet. And let me just
    conclude by saying, if our Nation can be bold enough to act
    upon these many unprecedented opportunities, we'll be amazed at
    what tomorrow will bring, and how swiftly we can turn discovery
    into health, as this title says. The one-size-fits-all approach
    to medicine will be a thing of the past; we will be using
    genetic information to personalize our healthcare.
        But, if you'll allow me, I see a future in which we will
    use stem cells to repair spinal cord injuries. We'll
    bioengineer bones and cartilage to replace wornout joints.
    We'll use nanotechnology to deliver therapies with exquisite
    precision. We'll pre-empt heart disease with minimally invasive
    image-guided procedures, and use an artificial pancreas or
    other new technologies to manage diabetes better.
        I look forward to a universal vaccine for influenza, so
    that you don't have to get a shot every year for the new
    strain. I look forward to the possibility, more possible now
    than ever, of an AIDS vaccine and a malaria vaccine. And I
    dream of a day when we'll be able to prevent Alzheimer's
    disease, Parkinson's disease, and many others that rob us, too
    soon, of family and friends.

                               PREPARED STATEMENT

        As you've heard, the fiscal year 2011 request from this
    subcommittee is $32.157 billion, an increase of $1 billion.
    These funds will enable the biomedical research community to
    pursue a number of substantial opportunities in these major
    scientific and health opportunity areas.
        So, I'm really grateful for the chance to be here this
    morning. I'm pleased to respond to any questions that you might
    have.
        Thank you very much.
        [The statement follows:]

                    Prepared Statement of Francis S. Collins

        Good morning, Mr. Chairman and distinguished members of the
    subcommittee: It is a great honor to appear before you today to present
    the fiscal year 2011 budget request for the National Institutes of
    Health (NIH), and to discuss my vision for the future of biomedical
    research.
        First, I'd like to thank each of you for your steadfast support of
    NIH's mission: discovering fundamental knowledge about living systems
    and then applying that knowledge to fight illness, reduce disability,
    and extend healthy life. In particular, I want to thank the
    subcommittee for the fiscal year 2010 budget level of $31 billion, and
    the $10.4 billion provided to NIH through the American Recovery and
    Reinvestment Act. I was very grateful for the subcommittee's interest
    and support over the course of my 15 years as Director of the National
    Human Genome Research Institute, most notably during our successful
    effort to sequence the human genome. Now, as steward of NIH's entire
    research portfolio, I truly believe that the opportunities for us to
    work together to improve America's health have never been greater.
        One of my first actions upon being named NIH Director was to scan
    the vast landscape of biomedical research for areas ripe for major
    advances that could yield substantial benefits downstream. I found many
    of the most exciting opportunities could be grouped under five main
    themes: taking greater advantage of high-throughput technologies;
    accelerating translational science, that is, turning discovery into
    health; helping to reinvent healthcare; focusing more on global health;
    and reinvigorating the biomedical research community.
        The administration's request of $32.1 billion for NIH's biomedical
    research efforts in fiscal year 2011 would help more researchers take
    greater advantage of these unprecedented opportunities, all with the
    aim of helping people live longer, healthier, more rewarding lives. We
    at NIH are fortunate to have a very solid foundation upon
        which to build, established by such extraordinary leaders as James
    Shannon, Nobel laureate Harold Varmus, Elias Zerhouni, and the late and
    much missed Ruth Kirschstein.

                             THE RESEARCH MARATHON

        In his fiscal year 2009 budget remarks, Dr. Zerhouni warned that
    our Nation's biomedical research effort is in a race that we cannot
    afford to lose. I wholeheartedly agree, and want to provide a few more
    insights about what that race involves.
        Science is not a 100-yard dash. It is a marathon--a marathon run by
    a relay team that includes researchers, patients, industry experts,
    lawmakers, and the public.
        Thanks to discoveries funded through NIH appropriations, we have
    covered a lot of ground in this marathon. Let us take a moment to look
    back at a few of the advances made possible by NIH-supported research,
    and then look ahead to some of our Nation's biggest health challenges
    and how NIH intends to meet them.

                               HOW FAR WE'VE COME

        U.S. life expectancy has increased dramatically over the past
    century and still continues to improve, gaining about 1 year of
    longevity every 6 years since 1990. A baby born today can look forward
    to an average life span of 77.7 years, almost three decades longer than
    a baby born in 1900.
        Not only are people living longer, they are staying active longer.
    From 1982 through 2005, the proportion of older people with chronic
    disabilities dropped by almost one-third, from 27 percent to 19
    percent.
        Some of the most impressive gains have been made in the area of
    cardiovascular disease. In the mid-20th century, cardiovascular disease
    caused half of U.S. deaths, claiming the lives of many people still in
    their 50s or 60s. Today, the death rate for coronary heart disease is
    more than 60 percent lower--and the death rate for stroke, 70 percent
    lower--than in the World War II era.
        What fueled these improvements? One major contributor has been the
    insights from the NIH-funded Framingham Heart Study, which began in the
    late 1940s and is still going strong. This population-based study,
    which changed the course of public health by defining the concept of
    disease risk factors, continues to break new ground with its recent
    move to add a genetic component to its analyses.
        Other factors include NIH-supported research that led to minimally
    invasive techniques to prevent heart attacks and to highly effective
    drugs to lower cholesterol, control high blood pressure, and break up
    artery-clogging blood clots. Science also played a crucial role in
    formulating approaches to help people make lifestyle changes that
    promote cardiovascular health, such as eating less fat, exercising
    more, and quitting smoking.
        Many chronic conditions have their roots in the aging process. One
    such disease, osteoporosis, can lead to life-threatening bone fractures
    among older people. NIH-funded research has led to new medications and
    management strategies for osteoporosis that have reduced the
    hospitalization rate for hip fractures by 16 percent since 1993.
    Science has also transformed the outlook for people with age-related
    macular degeneration, a major cause of vision loss among the elderly.
    Twenty years ago, little could be done to prevent or treat this
    disorder. Today, because of new treatments and procedures based on NIH
    research, 750,000 people who would have gone blind over the next 5
    years will continue to have useful vision.
        Biomedical research also has benefited those at the other end of
    the age spectrum. NIH-funded research has given hearing to thousands of
    children who were born profoundly deaf. This hearing is made possible
    through a cochlear implant, an electronic device that mimics the
    function of cells in the inner ear. Since the Food and Drug
    Administration (FDA) approved cochlear implants for pediatric use in
    2000, more than 25,000 children have received the devices, enabling
    many to develop normal language skills and succeed in mainstream
    classrooms.
        Then, there are the infectious diseases--diseases that often know
    no boundaries when it comes to age, sex, or physical fitness. One of
    NIH's greatest achievements over the past 30 years has been to lead the
    global research effort against the human immunodeficiency virus (HIV)/
    acquired immunodeficiency syndrome (AIDS) pandemic. With discovery
    building upon discovery, researchers first gained fundamental insights
    about how HIV works, and then went on to develop rapid HIV tests,
    identify a new class of HIV-fighting drugs, and, finally, figure out
    how to combine those drugs in life-saving ways in the clinic. As a
    result, HIV infection has changed from a virtual death sentence into a
    manageable, chronic disease. Today, HIV-infected people in their 20s
    who receive combination therapy may expect to live to age 70 or beyond.

                             HOW FAR WE HAVE TO GO

        Although we have accomplished much, and as tempting as it may be
    for NIH to rest upon its laurels, we all know that biomedical research
    still has an enormous amount of ground to cover before discovery is
    turned into health for all Americans.
        Consider the challenge posed by cancer. This disease still claims
    the lives of more than 500,000 Americans annually--about one every
    minute. But in 2007, for the first time in our Nation's history, the
    absolute number of cancer deaths in the United States went down. And,
    over the past 15 years, cancer death rates have dropped 11.4 percent
    among women and 19.2 percent among men, which translates into some
    650,000 lives saved--more than the population of Washington, DC. These
    are very encouraging milestones, but they are not nearly enough.
        NIH-funded research has revolutionized how we think about cancer. A
    decade or two ago, cancer treatment was mostly reactive, diagnosis was
    based on the organ involved and treatment depended on broadly aimed
    therapies that often greatly diminished a patient's quality of life.
    Today, basic research in cancer biology is moving treatment toward more
    effective and less toxic therapies tailored to the genetic profile of
    each patient's cancer.
        Among the early success stories in this area is the drug
    trastuzumab (Herceptin) for breast cancer. An NIH-sponsored clinical
    trial found that when breast cancer patients whose tumors were
    genetically matched to trastuzumab received the drug, along with
    standard chemotherapy, their risk of cancer recurrence fell 40 percent.
    That improvement is the best ever reported in postsurgical treatment of
    breast cancer. Studies also have found that the chemotherapy drugs
    gefitinib (Iressa) and erlotinib (Tarceva) work much better in the
    subset of lung cancer patients whose tumors have a certain genetic
    change.
        To accelerate the development of more individualized strategies for
    more types of cancer, NIH has tapped into the promise of high-
    throughput technologies to launch The Cancer Genome Atlas (TCGA). Over
    the next few years, TCGA's research team will build comprehensive maps
    of the key genomic changes in 20 major types and subtypes of cancer.
    This information, which is being made rapidly available to the
    worldwide scientific community, will provide a powerful new tool for
    all those striving to develop better ways to diagnose, treat, and
    prevent cancer.
        Already, TCGA has produced a comprehensive molecular classification
    system for ovarian cancer and glioblastoma, the most common form of
    brain cancer. The survey of glioblastoma recently revealed five new
    molecular subtypes of the disease. In addition, researchers found that
    responses to aggressive therapies for glioblastoma varied by subtype.
    The findings hold promise for matching the most appropriate therapies
    with brain cancer patients and may also lead to therapies directed at
    the molecular changes underlying each subtype, as has already happened
    for some types of breast cancer.
        Diabetes is another disease that is inflicting much damage on U.S.
    health. More than 23 million Americans currently have diabetes--nearly
    8 percent of the population. Another 57 million have blood sugar levels
    that indicate they are at serious risk of developing the disease, which
    is a major cause of kidney failure, stroke, heart disease, lower-limb
    amputations, and blindness.
        For type 2 diabetes, prevention appears to be the name of the game.
    This form of the disease, which accounts for more than 90 percent of
    diabetes among adults, often can be averted or delayed by lifestyle
    factors. The NIH-funded Diabetes Prevention Program (DPP) trial showed
    that one the most effective ways to lower the risk of type 2 diabetes
    is through regular exercise and modest weight loss. There is good
    reason to believe that such efforts may lead to a lifetime of health
    benefits. A recent follow-up study of DPP participants found the
    protective effects of weight loss and exercise persist for at least a
    decade. The United Health Group has recently announced a partnership
    with Walgreen's and the YMCA to implement the results of this
    groundbreaking NIH-funded research on a broad scale.
        More than one-third of adults in the United States are obese,
    according to the latest data from the National Health and Nutrition
    Examination Survey which is conducted by the Centers for Disease
    Control and Prevention (CDC). And there are signs that the next
    generation may face an even greater struggle. Over the past 30 years,
    obesity has more than doubled among U.S. children ages 2 through 5 and
    nearly tripled among young people over the age of 6. Those statistics
    translate into tens of millions of Americans who face an increased risk
    of type 2 diabetes, as well as cardiovascular disease, high blood
    pressure, certain cancers, osteoarthritis, and other serious health
    problems associated with excess body fat.
        To address America's growing problem with obesity, NIH has launched
    a variety of initiatives aimed at developing innovative approaches for
    weight control. One such effort, called the National Collaborative on
    Childhood Obesity Research, has pulled together experts from four NIH
    Institutes, the CDC, and the Robert Wood Johnson Foundation. One
    example of their work is the Trial of Activity for Adolescent Girls, a
    national study to develop and test school- and community-based
    interventions to get girls more involved in gym class, organized
    sports, or recreational activities. Another NIH program, called We
    Can!, provides families with practical tools for weight control at more
    than 1,000 community sites nationwide. How to get more people to lose
    weight is also among the questions being explored by OppNet, a new
    trans-NIH initiative for basic behavioral and social sciences research.
        Meanwhile, other NIH-funded researchers are busy uncovering
    information about genes and environment that may pave the way for more
    personalized, targeted strategies for controlling weight and preventing
    diabetes. For example, in just the past few years, we have identified
    more than 30 genetic risk factors for type 2 diabetes.
        A better understanding of genetic and environmental factors may
    also help solve a longstanding medical puzzle: the causes of autism.
    Children with autism spectrum disorders experience a range of problems
    with language and social interactions, sometimes accompanied by
    repetitive behaviors or narrow, obsessive interests. Recent studies
    funded by NIH have associated autism risk with several genes involved
    in the formation and maintenance of brain cells, but much more work is
    needed to follow up on these clues.
        In fiscal year 2011, NIH will support comprehensive and innovative
    approaches to piece together the complex factors that contribute to
    autism spectrum disorders. One ambitious effort will involve sequencing
    the complete genomes of 300 people with autism and their parents. Other
    researchers will examine a mother's exposure during pregnancy to
    identify possible environmental contributions. NIH hopes to use these
    insights to develop new molecular and behavioral therapies for such
    disorders, as well as to identify possible strategies for prevention.
        Another brain disorder, depression, presents a different set of
    challenges. Although researchers have made significant progress in
    understanding the biology of depression, improving treatment, and
    lessening the social stigma associated with mental illnesses, suicide
    still claims the lives of twice as many Americans as homicide. And it
    does not end there--untreated depression also increases the risk of
    heart disease and substance abuse.
        How can medical research reduce depression's tragic toll? One way
    may be getting people into treatment more quickly. Researchers today
    are using functional magnetic resonance imaging and other innovative
    technologies to see how the brains of people with depression differ
    from those without the disorder. Rapid diagnosis is just part of the
    equation. Finding the right antidepressant drug for any particular
    patient currently is a lengthy, trial-and-error process that can take
    weeks before symptoms are relieved. NIH supports laboratory research
    aimed at developing quicker-acting antidepressants, as well as genetic
    studies that will help to match individuals with the drugs most likely
    to work for them.
        In 2008, 143 soldiers died by suicide--the highest rate since the
    Army began keeping records three decades ago. To address this problem,
    NIH and the U.S. Army recently partnered to launch the largest study
    ever of suicide and mental health among military personnel. The Army
    Study to Assess Risk and Resilience in Service Members will identify
    risk factors that may inform efforts to develop more effective
    approaches to suicide prevention.

                       TRANSFORMING DISCOVERY INTO HEALTH

        Whatever the disease, be it depression, diabetes, or something much
    rarer, NIH's emphasis in fiscal year 2011 and beyond will be on
    translating basic discoveries into new diagnostic and treatment
    advances in the clinic.
        In the past, some have complained that NIH has been too slow to
    convert fundamental observations into better ways to diagnose, treat,
    and prevent disease. Although some of that criticism may have been
    deserved, most of the delay has stemmed from the lack of good ideas
    about how to traverse the long and winding road from molecular insight
    to therapeutic benefit.
        That is now changing. For many disorders, there are new
    opportunities for NIH to shorten and straighten the pathway from
    discovery to health. This expectation is grounded in several recent
    developments: the dramatic acceleration of our basic understanding of
    hundreds of diseases; the establishment of NIH-supported centers that
    enable academic researchers to use such understanding to screen
    thousands of chemicals for potential drug candidates; and the emergence
    of public-private partnerships to aid the movement of drug candidates
    identified by academic researchers into the commercial development
    pipeline.
        Let me give you one example of how NIH plans to implement this
    strategy: the Therapeutics for Rare and Neglected Diseases (TRND)
    program. This effort will bridge the wide gap in time and resources
    that often exists between basic research discoveries and the human
    testing of new drugs.
        A rare disease is one that affects fewer than 200,000 Americans.
    However, if all 6,800 rare diseases are considered together, they
    afflict more than 25 million Americans. Private companies seldom pursue
    new therapies for these types of diseases because of the high cost of
    research and low likelihood of recovering their investments. Effective
    drugs exist for only about 200, or less than 3 percent, of rare
    diseases. Unlike rare diseases, neglected diseases may be quite common
    in some parts of the world, especially in developing countries.
    However, there also is a dire shortage of effective, affordable
    treatments for many of these major causes of death and disability.
        Working in an open environment in which all of the world's top
    experts on a disease can be involved, TRND will enable certain
    promising compounds to be taken through the preclinical development
    phase--a time-consuming, high-risk phase often referred to as ``the
    valley of death'' by pharmaceutical firms focused on the bottom line.
    Besides speeding development of drugs for rare and neglected diseases,
    TRND will serve as a model for therapeutic development for common
    diseases, many of which are being resolved into smaller, molecularly
    distinct subtypes.
        NIH will also take other steps to build a more integrated pipeline
    that connects all of the steps between identification of a potential
    therapeutic target by a basic researcher and the point when the FDA
    approves a therapeutic for clinical use. Among the tools at our
    disposal is the NIH Clinical and Translational Sciences Award program,
    which currently funds 46 centers and has awardees in 26 States and
    plans to add even more in fiscal year 2011. This national network is
    pulling together interdisciplinary clinical research teams to work in
    unprecedented ways to develop and deliver tangible health benefits. We
    also need to take advantage of the Nation's largest research hospital,
    the Mark O. Hatfield Clinical Research Center, located on the NIH
    campus in Bethesda, Maryland. Just as they blazed a trail for safe and
    effective human gene therapy, NIH clinical researchers may be well-
    positioned to move the ball forward for other pioneering approaches,
    such as those using human embryonic stem cells or induced pluripotent
    stem cells derived from skin cells.
        To make the most of these new opportunities, the NIH and FDA
    recently forged a landmark partnership with the formation of a Joint
    Leadership Council. Members of this Leadership Council will work
    together to ensure that regulatory considerations form an integral
    component of biomedical research planning, and that the latest science
    is integrated into the regulatory review process. Such collaboration
    will advance the development of products to treat, diagnose and prevent
    disease, as well as enhance the safety, quality, and efficiency of
    clinical research and medical product approval.

                    BIOMEDICAL RESEARCH PROPELS U.S. ECONOMY

        It is crucial to keep in mind that investing in NIH not only
    improves America's health and strengthens our Nation's biomedical
    research potential, it empowers the entire U.S. economy. Consider the
    following statistics:
      --A report issued by Families USA calculated that in 2007, every $1
            in NIH funding resulted in an additional $2.11 in economic
            output in the United States.
      --In fiscal year 2007, a typical NIH grant supported the salaries of
            about 7 high-tech jobs in full or in part.
      --The 351,000 jobs resulting from NIH awards paid an average annual
            wage of more than $52,000 per annum and account for more than
            $18 billion in wages for fiscal year 2007.
      --Long-term, NIH-funded R&D sparks U.S. economic innovation in the
            high-technology and high value-added pharmaceutical and
            biotechnology industries. For example, between 1982 and 2006,
            one-third of all drugs and nearly 60 percent of promising new
            molecular entities approved by the FDA cited either an NIH-
            funded publication or an NIH patent.
      --Gains in average U.S. life expectancy from 1970-2000 were worth an
            estimated $95 trillion.

                               IMAGINE THE FUTURE

        If our Nation is bold enough to act today upon the many
    unprecedented opportunities now offered by biomedical research, we may
    be amazed at what tomorrow will bring.
        In the world I envision just a few decades from now, we will use
    stem cells to repair spinal cord injuries; bioengineered tissues to
    replace worn-out joints; genetic information to tailor health outcomes
    with individualized prescriptions; and nanotechnology to deliver
    therapies with exquisite precision. I also dream of a day when, in ways
    yet to be discovered, we will be able to prevent Alzheimer's,
    Parkinson's, and other diseases that rob us much too soon of family and
    friends.
        Just imagine what such a future would mean for our Nation and all
    humankind. This is what keeps NIH in the research marathon, and why we
    ask you to go the distance with us.
        Thank you Mr. Chairman.

                             NICVAX SMOKING VACCINE

        Senator Harkin. Well, Dr. Collins, thank you very much.
        I asked my staff to get me some more information on that
    smoking vaccine. It's just something I had not heard about.
    That could be phenomenal.
        [The information follows:]

                                Smoking Vaccine

        Tobacco remains the leading cause of preventable death in the
    United States, linked to more than 400,000 deaths each year. That is
    why the National Institutes of Health is accelerating research to
    eradicate tobacco addiction, including working with a private partner,
    Nabi Biopharmaceuticals, via a $10 million grant from the National
    Institute on Drug Abuse, to achieve that goal.
        American Recovery and Reinvestment Act (ARRA) funding released in
    September will help pay for the first phase III trial of NicVAX, a
    smoking cessation vaccine designed to help people quit and remain
    abstinent. It was given fast track designation by the Food and Drug
    Administration and has already successfully completed a proof-of-
    concept trial; successful completion of the phase III study will bring
    the vaccine closer to final approval.
        As a result of ARRA funding, Nabi entered an agreement with
    GlaxoSmithKline to receive an additional $40 million to exclusively in-
    license NicVAX on a worldwide basis and develop follow-on, next-
    generation nicotine vaccines, with the possibility of additional $500
    million depending on the outcome of the trial. This work is an
    excellent example of leveraging Government resources to further develop
    and market a medication for tobacco addiction.
        Similar to vaccines for infectious diseases, NicVAX works by
    stimulating the immune system to produce antibodies; in this case,
    however, to the drug nicotine. Nicotine (a small molecule) normally
    travels quickly through the lungs into the bloodstream and then to the
    brain. However, when nicotine molecules are bound to antibodies, they
    become too large to enter the brain, thus subverting the behavioral
    effects of the drug. Results to date show that smokers who achieved
    high antibody levels had higher rates of quitting and longer stretches
    of abstinence than those given placebo (18 percent vs. 6 percent
    complete abstinence after 52 weeks). The vaccine was also well
    tolerated, with few side effects.
        NicVAX's unique immunological mechanism of action elicits anti-
    nicotine antibodies lasting for several months--a potential benefit
    over current therapies. Early results showed that it reduced craving
    and withdrawal symptoms, which often prompt relapse. This should
    improve smokers chances to end the addiction/relapse cycle that plagues
    the great majority of those trying to quit.
        A successful phase II proof-of-concept trial was completed in late
    2007, in which NicVAX showed significant improvement in smoking
    cessation rates and continuous long-term smoking abstinence compared to
    placebo, in those who achieved high antibody levels. For the phase III
    trial, modifications were made to the original protocol to improve the
    likelihood of success. An additional vaccination was added and the
    timing of the quit attempt was modified to coincide with the optimal
    level of antibody response. Twenty-two investigative sites have been
    selected, and include highly experienced academic-based smoking
    cessation centers and experienced nonacademic sites. The study will
    enroll 1,000 subjects who want to quit smoking. They will be randomized
    to 1 of 2 treatment groups: (1) placebo control or (2) active vaccine
    treatment.
        Participants will be followed for 1 year from the start of
    immunization. The study's main goal is to determine the percentage of
    those who are abstinent during the final 16 weeks of the study (weeks
    37-52). Other endpoints include safety, withdrawal symptoms, craving,
    cigarette consumption, evaluation of the smoking experience, short-term
    cessation rates after each injection, and assessment of abstinence.
        Recruitment for the phase III trial is on target and the study is
    going well. Final data are expected within 2 years of study start,
    which was in November 2009.

        Dr. Collins. Yes, indeed.
        Senator Harkin. I mean, from prevention we know what
    smoking leads to, and all the diseases it leads to, and the
    cost to society. And most people I meet that have been on
    smoking want to stop, but they just have a tough time.
        Dr. Collins. They do, indeed.
        Senator Harkin. So, this could be remarkable. Do you know
    when--how--that trial is ongoing right now?
        Dr. Collins. It's ongoing, reasonably recently started. I
    can find out for you the expected end date of the trial, but
    they're certainly pushing this forward with all due speed.
        [The information follows:]

        To find the recent clinical trials go to: http://www.cancer.gov/
    clinicaltrials/lung-cancer-updates.

        Senator Harkin. Now, let me ask you this, Doctor----
        Well, let's start a 6-minute round? Is that what we have,
    here? Who's operating my clock? There we go. Okay, fine.
        Dr. Collins, I noticed, on the funding, here, for next
    year, how some Institutes go up by 3.2 percent, some by 2.5
    percent, some by 2.8 percent, some by--and they're all over the
    place. I assume they are some of these differences accounted
    for by focusing on those thematic areas that you just
    mentioned, those five theme areas? Is that what is driving that
    now?
        Dr. Collins. That's exactly right.
        Senator Harkin. What----
        Dr. Collins. Those five themes seem to be areas of
    exceptional opportunity. When we looked at the investments of
    the various Institutes in those areas a couple of years ago--
    which is not a perfect, but a somewhat good predictor of what
    might be possible in fiscal year 2011--it was clear that those
    opportunities are not entirely evenly distributed. And so,
    recognizing that that $1 billion, although it's only going to
    keep up with inflation, still ought to be invested in
    innovative ways, we attempted to do some arranging of the
    budget to reflect that, and that's what you see in those
    differences between Institutes. They're modest, but they are
    important, I think, to point out, that we're not just doing
    everything in lockstep.
        Senator Harkin. Well, one has to always be careful when
    you're dealing in percentages.
        Dr. Collins. Yes.
        Senator Harkin. As I've often pointed out, zero-to-one is
    an infinite increase. So, sometimes those that get very little
    funding, to get them up a little bit, looks like it's a huge
    percentage increase. So, I always want to be careful and look
    at the percentage increases there.
        Dr. Collins. Point taken.
        Senator Harkin. Well, for instance, the Library of Medicine
    has 4 percent. Well, but it's so small, line of increase
    amounts for that. So, I always like to look at that very
    carefully.
        Dr. Collins. You're quite right, Senator.

                         FISCAL YEAR 2010 AND POST-ARRA

        Senator Harkin. The other one I wanted to get into, here,
    with you is on the funding cliff. So, we put the money in the
    ARRA. At the time, it was decided that we'd put that in, it was
    a 2-year slug of money for at least the following reasons: one,
    because we didn't want researchers being laid off; we wanted to
    keep people employed. A lot of researchers were in the middle
    of projects and studies that we did not want to interrupt. But,
    we knew that we were probably going to face this, 2 years from
    now. So, I guess my question is, What kind of challenges are
    you facing? How do you provide for this soft landing? Are we
    facing any interruptions at all--in terms of some science
    that's being done right now because of this cliff?
        Dr. Collins. So, Senator, this is the question that keeps
    me up at night. On the screen there, you'll see what the total
    funding for NIH has been over the last 10 years, and those red
    bars there are the dollars that came from the ARRA, which we
    are deeply grateful for, and which provided a real shot in the
    arm for some exciting, innovative research that, otherwise,
    would have had to wait a long time to get started; things like
    the Cancer Genome Atlas, for instance, which really was able to
    move forward at an unprecedented pace because of the
    availability of those funds.
        But, as you can see, the difference between fiscal year
    2010, total, when you include the $5.2 billion of ARRA dollars,
    compared to the President's budget for fiscal year 2011 is
    certainly a drop, and that's the cliff that everybody talks
    about, right there, about $4 billion.
        Senator Harkin. Right.
        Dr. Collins. We have done what we can, in anticipation that
    this might be a really challenging year, to try to be sure that
    the ARRA dollars were invested, as much as possible, in short-
    term needs. So, for example, $1 billion of this has gone to
    construction in the extramural community. Additional dollars
    have gone to equipment needs, things that were one-time
    requirements. And some dollars have gone to projects that we
    thought we could get done in 2 years, although that's a very
    short cycle time for a scientific project.
        But, we also felt that this was an opportunity to stimulate
    some real innovations and to get people to put forward some
    out-of-the-box ideas; and they did, in huge numbers. The
    Challenge Grants, for example, we thought we might get 4,000
    applications; we got 20,000. There was a great pent-up need
    here for support for new ideas. And many of those are, in fact,
    funded and will have, now, the question in their minds, ``What
    do we do after the 2 years is expended?''
        One thing we are doing is to encourage those who believe
    that they can't quite finish their project and they haven't
    quite spent all the money in 2 years, to ask for a no-cost
    extension, and we will consider those quite seriously. And if
    it seems reasonable, and they're making reasonable progress, we
    will grant that, so at least to stretch out this cliff a little
    bit.
        But, there's no question that the consequences of this
    situation are going to be significant. We currently estimate
    success rates for NIH grantees--which have been in the 25 to 35
    percent level for most of the last 30 years, and are now at 21
    percent, are going to drop further in fiscal year 2011, at this
    budget level, probably to about 15 percent. That's one chance
    out of seven that a given grant would get supported. And
    there's no question that is going to be stressful for all of
    us.
        Senator Harkin. That's not good.
        Well, we've been wrestling with this, ourselves. I am of
    the opinion that we need to do more at NIH. The question is,
    Where do we get the funding and--with all of the other things
    that the Appropriations Committee has to do, and with budget
    constraints? But, we'll see what we can do.
        I want to get one question--well, I'm down to zero. I'll
    ask the question after Senator Cochran gets through with his.
        Senator Cochran.

                           DISCOVERIES ON THE HORIZON

        Senator Cochran. Mr. Chairman, thank you very much.
        Dr. Collins, thank you again for being here and helping us
    review the budget request and pointing out your views of how we
    should identify the priorities and the most important ways we
    can use the funds available to this subcommittee.
        We know that you're a research scientist, and you've been
    rewarded with a lot of recognition, medals, and honors, because
    of the outstanding research you have done, and it reminds me of
    Dr. Arthur Guyton's success as a researcher at the University
    of Mississippi Medical Center. The University continues to
    perform research there. And although he's no longer with us, he
    had a fascinating and very influential impact on heart disease
    and its understanding and therapies to help people live longer
    and have better lives.
        Is there anything going on in the research field right now
    that rivals the work you, personally, did and were praised so
    highly for, and Dr. Arthur Guyton, as well? Do we have any,
    really, blockbuster researchers out there that you've
    identified in helping us provide funding for?
        Dr. Collins. Well, yes, I'm happy to tell you, there is an
    amazing cadre of creative, innovative, productive scientists
    now involved in biomedical research. I certainly agree that Dr.
    Guyton was a legendary character. I studied his book when I was
    in medical school; that's how I learned a lot about physiology
    and about the heart.
        And when you look around today--well, you could count Nobel
    Prizes, I suppose. NIH has been the source of support for no
    less than 131 Nobel Prizes over the last few decades. And, in
    fact, this past fall, when the Nobel Prizes were given out,
    both for medicine and for chemistry, of the six awardees, five
    of them were our grantees. Remarkable people, people like Liz
    Blackburn and Carol Greider, who were awarded the prize for
    discovering telomeres and the enzyme that maintains those ends
    of the chromosomes, so they don't get ratty, like your
    shoelaces, if you didn't have some way to protect those ends.
    Remarkable stories, all of those.
        Many of them coming from a direction you couldn't have
    predicted, but one of the wonders of the way NIH has been able
    to support research is that we base our decisions, many of
    them, on what comes across to us by investigators with ideas
    that go through the most rigorous peer-review system in the
    world, and then are given the funds to chase after those ideas.
        A new program that we're investing in, called the Pioneer
    Awards, is particularly trying to identify those very creative
    individuals who we could unleash to follow their ideas, and not
    have them quite so constrained by the systems that sometimes
    are in place, that--we need to track research, but there are
    times where you want to let somebody just go for it. And we're
    determined to use those kinds of mechanisms and things like New
    Innovators to make that happen.
        In that--particular areas that NIH is supporting, I will
    mention cancer, because I think we are, actually, at a
    remarkable moment, in terms of being able to understand, at
    that most detailed DNA level, what goes wrong in a cancer cell;
    not just some of the things, but all of the things that go
    wrong in a cancer cell. Why does a good cell go bad? And what
    could we use as--with that information, to develop therapies
    that are targeted--like Kate Robbins, the case I told you
    about--specifically toward their tumor? That was a pipedream 5
    or 6 years ago. Now it is absolutely transforming people's
    ideas of how to go forward. And the researchers working on
    that--many of them 20-somethings, many of them with
    computational backgrounds, because a lot of the challenge now
    is to figure out how to analyze the mountains of data that can
    be produced. They are remarkable to hang out with.
        So, I'm actually quite inspired by our cohort of
    researchers. My concern is, we need to be sure we're giving
    them the confidence that that support is going to be there, so
    that they stick it out and are willing to take risks and not
    just do the obvious next steps.

                              JACKSON HEART STUDY

        Senator Cochran. One of the undertakings in our State is
    the Jackson Heart Study, which has been a comprehensive review
    of the individual medical histories of people who have heart
    problems, and seeing if we can identify factors that can be
    changed or corrected to help us do a better job of providing
    opportunities for healthy lives, rather than a destiny that is
    more likely to involve heart problems. What is the status of
    that study? And are you requesting funding, in this budget
    request, to continue or go forward from that study to something
    else?
        Dr. Collins. We are very enthusiastic about that study,
    Senator, and delighted by your strong support of this from the
    beginning. So, this is carried out in Mississippi, in Jackson,
    with the University of Mississippi and Tougaloo College
    participating. NIH has a big role in this, supported by the
    National Heart, Lung, and Blood Institute (NHLBI). And already,
    a lot of very important observations have come forward
    studying, particularly, cardiovascular disease in African
    Americans, about which we didn't know enough, and now we're
    starting to learn.
        So, for instance, we're learning that hypertension and
    obesity and diabetes, the three of those together, the so-
    called ``metabolic syndrome,'' occurs at phenomenally high
    rates in this group. We're also learning that even individuals
    of normal body weight have a higher incidence of hypertension
    and diabetes in this group, and that's a puzzle, and a question
    is trying to be answered now: Is that diet? Is that
    environment? Is that genetics? We have to figure out what are
    those causes, because obviously these are diseases that have a
    great deal of consequence, in terms of heart disease and
    strokes.
        We are learning that this kind of gathering together is
    also a great way to get community involvement. And the ways in
    which the Jackson Heart Study has embraced the community, and
    been embraced by the community, is a wonderful model for doing
    research on health disparities.
        The funding for 2011 for the Heart Study is very much a
    part of this budget, and the NHLBI intends to continue that at
    least through 2013. At that point, they will be evaluating what
    progress has been obtained. But, everything I have heard from
    the leadership is, they're--they expect to continue this for a
    long time.
        Senator Cochran. Well, thank you very much.
        Thank you, Mr. Chairman.

             INSTITUTE OF MEDICINE (IOM) REPORT ON CLINICAL TRIALS

        Senator Harkin. Thank you, Senator Cochran.
        I've got two or three things I'd like to follow up on,
    here.
        Dr. Collins, last year President Obama vowed to find,
    quote, ``a cure for cancer in our time.'' But, I remember when
    President Nixon declared a war on cancer. They've been fighting
    that thing ever since. So, while I appreciate the President's
    vow, I just wonder if we're going in the right direction.
        Now, you've come up with some things here that give us a
    lot of hope, but, just recently, the IOM issued a report that
    was very critical of the National Cancer Institute's (NCI)
    Clinical Trial Network (CTN). According to the IOM, the CTN is
    underfunded, and is approaching, ``a state of crisis.'' Most
    disturbing of all, about 40 percent of its cancer trials are
    never completed, which might suggest that we're wasting
    valuable time and money.
        So, again, I want to give you the opportunity to respond to
    that. The IOM report found that the CTN is too bureaucratic,
    its research is poorly coordinated. Due to cumbersome review
    procedures, the average time between developing an idea for a
    trial and getting it started is about 2 years. Another problem
    they pointed out was the distressingly low participation rate
    of adults in clinical trials. So, I wanted to kind of go over
    that with you and how are you responding to this IOM study.
        Dr. Collins. Senator, I think all of us are quite concerned
    about this situation. Certainly, I've studied that IOM report
    carefully and talked to the leadership at the NCI about this.
    The cooperative groups, 10 of them, that have been conducting
    clinical trials on cancer for as long as 50 years, have
    certainly produced wonderful data over the course of time. But,
    there's no question that the current system is not functioning
    as well as it should. And that's what this report pointed out.
        I should mention that it was Dr. Niederhuber and the
    leadership of the NCI that asked for the IOM to look at this,
    so they were fully aware of the need for some changes, and
    asking IOM to help out with this, and are now, I think,
    embracing that report and already moving forward to try to make
    such changes.
        Clearly, there are a number of serious issues here. One is
    the very long time, as you've mentioned, between the time when
    a protocol is conceived and when the first patient is enrolled.
    And that had stretched out to 2\1/2\ years. Well, here we have
    a field that's moving so quickly, by the time you get to the
    point of enrolling a patient, sometimes the protocol didn't
    seem like one that you would really want to support at that
    point. So, that timetable has to be shortened. NCI has moved
    forward, now, to make changes that will limit that to 1 year,
    and no more.
        And obviously, part of this is our own system of trying to
    run multicenter trials, which has gotten really quite
    convoluted and complicated, in the sense that, particularly,
    for human-subjects approval, every center has its own IRB, and
    the IRB has to review the consent form. And if you're trying to
    run a trial that involves dozens of centers, and every IRB
    wants to tweak things a little bit, you can see how time passes
    and you don't end up with things getting underway very quickly.
        Senator Harkin. Why can't----
        Dr. Collins. Furthermore, there may be----
        Senator Harkin. Why don't we consolidate that?
        Dr. Collins. Well, exactly. We need central IRBs, and there
    is a major move underway to implement that. It has been, I
    think, delayed by the fact that many legal minds have been
    involved, saying that institutions shouldn't really deem anyone
    other than their own IRB as capable of reviewing----
        Senator Harkin. Do we have to do anything legislatively,
    Dr. Collins?
        Dr. Collins. I think this actually can be handled without
    legislation. I will tell you, there's a great groundswell now,
    not just from cancer, but from many other areas of clinical
    research, to do something to streamline our human-subjects
    effort, that we are not really, in every instance, using this
    in a way to protect participants in research, but we've gotten
    all tangled up in the bureaucracy. And sometimes we are mixing
    up the things that are really high risk with things that are
    very low risk. And we need a revamping there. And I think this
    is something that's going to get attention quite soon.
        Other areas--there's a problem, in some instances, where
    protocols may be run in too many centers, and each center is
    only enrolling a very small number of patients. And so, it's
    not an efficient way to do things.
        There may not be a sufficient evaluation of whether a
    protocol is actually the best use of the money for that disease
    at that point. There needs to be more of a scientific rigor in
    the process.
        All of those are accepted, now, I think, by the NCI.
        There will be new leadership of the NCI; an announcement of
    that sort is imminent. And I am sure the new NCI Director will
    take this on as a very high priority, to try to understand how
    best to re-engineer this CTN, because this is critical for our
    future. We're going to have a much higher throughput of new
    molecular entities coming forward from this molecular
    understanding of cancer, and we have to have an engine in place
    to test them and see what works and what doesn't. So, this
    could not be more important, and I appreciate your raising the
    issue.

                              ALZHEIMER'S DISEASE

        Senator Harkin. Well, thank you. I have a couple more. I
    had a question that has to do with Alzheimer's, but maybe a
    little bit broader than that.
        A panel, convened by NIH, issued a finding, last month,
    that left a lot of people confused, I think, about Alzheimer's.
    According to this panel, there is no evidence that any of the
    strategies that people have been told to use to prevent
    Alzheimer's actually makes any difference. That includes
    getting exercise, taking supplements, keeping your mind active,
    doing crossword puzzles, and so forth. According to this panel,
    there's no evidence that any of these measures prevent you from
    getting this disease.
        So, one question on that would be how we interpret a
    finding like that. The other question about Alzheimer's has to
    do with a broader level of funding, and how we think about
    funding for different diseases.
        But, let's focus on this one, first, about the finding.
    What do we tell people? How do we interpret this finding?
        Dr. Collins. Well, I think there have been a lot of
    messages out there that people were confused by--what works,
    what doesn't work. The whole point of the NIH panel was to
    actually look at the evidence and try to see, What do we
    objectively know about measures that could be used to delay or
    prevent this disease? Because this is a disease that affects,
    obviously, very large numbers of people, and we're all
    concerned about it. I just turned 60; I'm thinking about this
    more than I used to.
        And, basically, all of the things that were put forward as
    potentially being beneficial in reducing the risk haven't held
    up very well to rigorous scientific evaluation. It looks as if
    doing crossword puzzles or doing Sudoku, it makes you better at
    doing crossword puzzles and doing Sudoku.
        It isn't clear that there's evidence it has a more global
    effect, in terms of protecting your mental capacities as you're
    getting older.
        The one exception that they thought perhaps there was some
    evidence for is diet, and particularly Omega-3 fatty acids,
    which are something that you find in fish. And there is some
    data supporting that as a possible preventive measure, and that
    one deserves more study. But, it was one bright light.
        And then, of course, there are well-documented
    environmental influences that we know about. Smoking, for
    instance, is clearly a risk factor for Alzheimer's, as well as
    a long list of other things. And certainly, obesity seems to
    have a connection, as well.
        But, in terms of the specific mental exercises, which I
    think was one of the disappointments for a lot of people who
    hoped that that would be a way that you could take control of
    the situation and help yourself, there didn't seem to be
    evidence to support that.
        Senator Harkin. Thank you.
        Senator Cochran.

                           INSTITUTIONAL DEVELOPMENT

        Senator Cochran. Mr. Chairman, thank you.
        We were talking, in my first round of questions, about the
    University of Mississippi and the legacy of Dr. Arthur Guyton.
    One thing that this subcommittee decided to do a few years ago
    was to earmark--oh, heaven forbid--some money, in this
    particular bill, and target the funding for grants and research
    to institutions in States that were getting less money and less
    attention to their work and applications than many other States
    had--which had long records of success and notoriety in certain
    areas.
        Now, the University of Mississippi Medical Center, it was
    benefited greatly from one person's influence--Dr. Arthur
    Guyton. We talked about that. But, there are other
    institutions--within small States, in particular--who just come
    out on the short end of the stick when they apply for grants
    and try to get Federal support for work they're doing. Some of
    the ideas may be good, but the money is just never--never finds
    its way to those institutions.
        So, we set aside, in fiscal year 2009, $224 million in a
    program designated for Institutional Development Awards. The
    purpose of that is to spread the money out in areas that would
    not, probably, be seriously considered for grants, finding and
    looking for the activities and the research that's being done,
    and having national impact and importance.
        I guess my question is--Mississippi received $5 million--a
    little over--of the amount appropriated. That's only 2.4
    percent of the total, so it's not like we out-maneuvered
    everybody; we didn't. But--and I guess that's the reason for my
    question. Some States do better than others in this, and I was
    just wondering, Is there any way for--a more careful review can
    be made to be sure that the intent of the set-aside is carried
    forward and that some States are not treated too much better
    than everybody else, so--the consequences of being left out?
        Mississippi shares 2.4 percent, for example. That doesn't
    sound like much to me. What are your thoughts about how we
    could better define what this money is for to make sure it
    carries out the intent of the Congress?
        Dr. Collins. Well, thank you, Senator.
        So, yeah, the Institutional Development Awards (IDEA), have
    been strongly supported by NIH. They're administered by the
    National Center for Research Resources. And, yes, the budget
    for fiscal year 2010 was--went up $229 million. These are
    competitive, they are available to the States who are
    identified as IDEA States, one of which is Mississippi, but
    there are a number of others that are traditionally underfunded
    by NIH, oftentimes because they have a lower proportion of
    institutions that are heavy in research efforts. But, we felt
    that we needed to be sure--we were finding opportunities in
    those States, and that those States had opportunities for NIH
    funding.
        There are a couple of specific programs: The Centers of
    Biomedical Research Excellence, COBRE, or ``Cobra,'' is one.
    There's an IDEA Network of Biomedical Research Excellence,
    INBRE. And, in fact, most of the States in the IDEA Network
    have been applying for those, and many of them with
    considerable success. But, it is a competitive program, where
    the peer-review system kicks in. And so, because of our
    interest in making sure that, with the funds available, we
    support what seems to the experts, who are not biased toward
    any particular State, but are trying to identify the best use
    of the money--we have to see where those outcomes fall.
        Another program, though, that is, I think, relevant, here,
    is actually the ability, through the ARRA, to support
    construction efforts that have been asked for in the IDEA
    States. And Mississippi recently received such a construction
    grant; Arkansas did. In fact, a number of the IDEA States, for
    this $1 billion of construction money, that were part of the
    ARRA, have been quite successful. And we're delighted to see
    that, because that may be a way, then, to build that capacity,
    so that, in the coming years, they'll be in an even better
    position to be highly competitive for these funds.
        Senator Cochran. Thank you very much.
        Senator Harkin. Senator Specter.

                       STATEMENT OF SENATOR ARLEN SPECTER

        Senator Specter. Thank you, Mr. Chairman.
        Dr. Collins, I join my colleagues in welcoming you here.
    Thank you for taking on this important job.
        My view, as expressed repeatedly, is that the National
    Institutes of Health are the crown jewels of the Federal
    Government--perhaps the only jewels. And in an era where we are
    searching for ways to prolong lives, save lives, and save
    money, it seems to me that we ought to be funding NIH a lot
    more aggressively than we are.
        Senator Harkin and I led the way, with Senator Cochran's
    concurrence, and others, to raise NIH funding from $12 to $30
    billion, $10 billion more than the stimulus. And the stimulus,
    I have heard, has created a whole wave across America of a--may
    the record show the witness is nodding in the affirmative----
        Dr. Collins. Yes, he is.

                                      CAN

        Senator Specter [continuing]. Great surge of enthusiasm and
    rekindled a lot of interest in young people, who had been very
    much concerned because the funding had tapered off. There had
    been a loss of real dollars--in excess of $5 million--when we
    had to--accommodated for cost of living adjustments and also
    some across-the-board cuts.
        And last year's funding was disgraceful, at $772 million.
    And this year's funding is also disgraceful, in my opinion, at
    $1 billion, with the comment made, ``Well, you got $10 billion
    before,'' but it wasn't meant to lessen the annual funding. So,
    I'm going to repeat a message to you, which I have made
    frequently; that is that the scientific is going to have to
    become a lot more politically active blowing your horn. The
    statistics are very impressive as to what the increased funding
    did for NIH on mortality rates, on strokes, and much progress
    on many strains of cancer, and heart disease, and right down
    the line. And I think what you have to do, for the Congress and
    for the administration, is show how many dollars it saves.
        Senator Harkin has been a real leader here on what he has
    done on wellness, the new concept, the Harkin Wellness
    Doctrine, a little exercise and annual exams and catching off
    ailments before they become chronic and debilitating and
    expensive. A lot of money to be saved by research; tremendous
    amounts of money to be raised by research.
        And your medical communities have gotten a lot of money.
    University of Pittsburgh has gotten $4 billion in the last
    decade. And it's so across the country. You got a lot of
    prominent people on those boards, politically influential
    people. And appropriations run on politics, on the pressure.
    You've got a great case, but it hasn't been expressed very
    well. And I don't fault Dr. Zerhouni or the prior--he was a
    great director----
        Dr. Collins. I agree.
        Senator Specter [continuing]. And staffed by great people.
        Now, I understand that you convened a meeting of your 27
    Institutes to talk about CAN, which is new. And it has been put
    forward to bridge the gap, so-called valley of death, as I've
    heard it expressed in the scientific community, between the
    bench and bedside, between research and practical application.
    It has an authorization of $500 million, not a whole lot of
    money for that kind of a project, but what is--first of all,
    can you confirm the meeting that the 27 Institutes got together
    on CAN and what was the thrust of the conversation?
        Dr. Collins. Well, thank you, Senator. And let me, first,
    say how appreciative your leadership has been over these years
    in supporting the cause of biomedical research, and
    particularly the critical role you've played for NIH support,
    including the ARRA funding, which, as you've alluded to,
    provided a remarkable shot in the arm for the research
    community and is being spent, I think, in truly exciting ways.
        With regard to the CAN, this part of the healthcare reform
    legislation, as you know, puts forward a proposal of having the
    NIH take on, in new and flexible ways, the acceleration of the
    process of going from a basic science discovery to a clinical
    advance; a drug therapy, most likely, but this would also apply
    to other kinds of clinical advances. We did discuss this last
    Thursday, all of the Institutes' directors together for a full-
    day retreat.
        Senator Specter. I heard there was a lot of enthusiasm for
    it.
        Dr. Collins. There was a lot of enthusiasm. People were
    delighted about the potential, here, because the science has
    reached the point of making this a real possibility. Not that
    NIH would become a drug development company, but the
    partnerships that we could now establish between NIH and the
    private sector through this kind of legislation are really
    exciting and unprecedented and are being very well received,
    both by the academics and people in companies.
        Senator Specter. What is your professional judgment as to
    the kind of priority attention that the CAN ought to receive?
        Dr. Collins. From my perspective, this is one of the five
    themes that I published in Science magazine as being most
    worthy of high-priority attention. The CAN fits very nicely
    into that, but provides some additional flexibility. So, this
    is a very high priority for us, and obviously we are mindful of
    the fact that, at the moment, this is authorized, but not
    appropriated. And we are also mindful of the fact that this may
    be a difficult year, in fiscal year 2011, with the ending of
    the ARRA dollars. But, certainly, from my perspective, as the
    NIH Director, and speaking for all those other Institute
    directors, this is something people are very anxious to get
    started on, and they have great hopes for, recognizing this is
    high-risk research, that many drug development programs fail,
    that if we're going to undertake this, we have to be prepared
    for that. But, I think we could learn a lot by doing this in a
    new way.
        Senator Specter. Many programs fail and many programs
    succeed.
        Dr. Collins. Indeed.
        Senator Specter. And the successes have been monumental in
    what you have done for prolonging and saving lives. What could
    you do with the $500 million, Dr. Collins? Tell this
    subcommittee how much you could accomplish with it.
        Dr. Collins. So, to undertake a project where you go from a
    basic science discovery to a Food and Drug Administration (FDA)
    approval of a drug is several years and expensive effort. With
    $500 million, we could probably proceed with about 20 projects,
    simultaneously, that went all the way from soup to nuts in that
    pipeline, and probably another 20 where we identify compounds,
    that are already in freezers of companies, that have been
    abandoned for various reasons, because they didn't work out for
    one application, but they might work out for a different one,
    so-called ``repurposing,'' which would allow you to skip over
    many expensive steps. That would be quite a bold effort,
    indeed, to take on roughly, then, 40 projects on 40 different
    targets.
        Senator Specter. One final comment, with the red light on.
    I would like you to go back to your office and review what
    could be accomplished with the $500 million, in as specific
    terms as you could, what you project you could do with that.
    And I know it is very hard to talk about saving lives, but you
    have some experience in what has gone on in other lines,
    statistically; and to the extent you could quantify it on
    saving lives, prolonging lives, or saving money, I think it
    would be very helpful, when the Chairman and the rest of us sit
    down to allocate the funds, here.
        This is a very difficult subcommittee, having the Labor and
    Health and Human Services, and Education Departments. The
    competition for the money is absolutely fierce. So, the more
    specific you can be, the stronger the case can carry.
        Thank you, Dr. Collins.
        Thank you, Mr. Chairman.
        Senator Harkin. I just want to, first of all, say that this
    whole CAN that we put into the healthcare reform bill was a
    singular effort by Senator Specter.
        [The information follows:]

                        Cures Acceleration Network (CAN)

        As you know Senator Specter, the Cures Acceleration Network (CAN),
    authorized in the Patient Protection and Affordable Care Act of 2010,
    would provide the National Institutes of Health (NIH) with new
    authorities to advance the development of ``high need cures'' by
    smoothing the pathway for developing new drugs, biologics, and devices,
    particularly through the so-called ``valley of death'' phase of the
    therapeutic pipeline. CAN would provide NIH with new authorities and
    flexible funding mechanisms, including the ability to leverage the
    Government's investment through matching funds. In addition to
    supporting the development of novel compounds and the repurposing
    abandoned products, it would provide NIH with an opportunity to carry
    out systematic process engineering that would result in a more
    efficient and effective therapeutic development pipeline. The program
    would operate in close coordination with the Food and Drug
    Administration and private sector stakeholders. CAN's authorities would
    allow us to use three novel funding mechanisms--Cures Acceleration
    Grant Awards, which could allow up to $15 million per award and
    additional funds in subsequent years; Cures Acceleration Partnership
    Awards, which could allow us to leverage additional funds so that a
    total of $20 million could be put toward every $15 million award; and,
    Cures Acceleration Flexible Research Awards, which could allow
    discretionary use of other funding mechanisms for up to 20 percent of
    the appropriation.
        Methicillin-resistant Staphylococcus aureus (MRSA) provides an
    example of how CAN could contribute to improving health, saving lives,
    and lowering healthcare costs. MRSA is a major and growing clinical and
    public health challenge, and there is a need to develop antibiotics
    that are effective in treating this potentially life-threatening
    infection. MRSA occurs in hospitals and other settings where people are
    in close contact with one another, including nursing homes,
    dormitories, military barracks, athletic centers, and prisons. All
    sectors of the population are vulnerable, and certain groups are at
    higher risk, including children, the elderly, and people with
    concurrent health conditions. In 2005, MRSA caused approximately 94,000
    invasive infections and 19,000 deaths. Total hospital costs for
    patients with MRSA infections were more than twice as high as those for
    patients with methicillin-treatable Staph infections ($34,657 compared
    to $15,923).
        Industry interest in developing new antibiotics for drug-resistant
    infectious diseases like MRSA has declined considerably in recent
    years. Since 1999, 10 of the 15 largest companies have fully abandoned,
    or cut down significantly, discovery efforts in this field.\1\ CAN
    could help address the deficits in the antibiotic drug development
    pipeline for treatments for MRSA and other drug resistant pathogens by
    leveraging established research resources, bringing together the
    pharmaceutical industry, regulatory and the financial communities, and
    applying necessary incentives to identify compounds for later phase
    development of new antibiotics. CAN's approach could make important
    contributions to this area.
    ---------------------------------------------------------------------------
        \1\ Kresse, H et al. The antibacterial drugs market. Nature Reviews
    Drug Discovery, January 2007.
    ---------------------------------------------------------------------------
        The de novo development and characterization of each new drug ready
    for clinical testing would require approximately $20 million. The
    repurposing of a drug, which has already undergone considerable
    chemical and biologic characterization, would require approximately $5
    million. An appropriation of $500 million would therefore allow us to
    support approximately 20 novel drug development projects and another 20
    projects using compounds that have been abandoned for lack of capital,
    market demand, or regulatory and developmental hurdles. We anticipate
    that the program would eventually make major contributions to improving
    health, saving lives, and lowering healthcare costs associated with
    many serious human disorders and conditions that currently lack
    effective therapies and pose major burdens for individuals, their
    families, and society.

        Senator Specter. Thank you, Mr. Chairman.
        Senator Harkin. He really dogged that one. And since I wear
    the other hat, as chairman of that other committee, too--this
    is one that Senator Specter championed and got in there and was
    on us all the time to make sure that it was not dropped. And
    so, it was held in there, and I thank him for that.
        I agree that this is something that really needs to be
    done, and we've talked about it personally many times in the
    past. And, Senator Specter, I think, has really been the great
    leader on this one.
        Again, of course, Arlen also put his finger on it--we have
    a lot of competition for a lot of money here, and we have
    constrained budgets. So, I'm going to play a little bit of the
    devil's advocate here.
        What would funding the CAN up to that $500 million, or
    however close--what would that allow NIH to do, that it can't
    do now?
        Dr. Collins. No, it's appropriate to----

              THERAPEUTICS FOR RARE AND NEGLECTED DISEASES PROGRAM

        Senator Harkin. Why can't you do it now?
        Dr. Collins. It's appropriate to ask those questions. So we
    are, in fact, pushing this translational agenda in innovative
    ways. There's a program that this Congress has funded, the
    Therapeutics for Rare and Neglected Diseases, the TRND program,
    which aims to try to fill in some of the missing pieces in the
    ``valley of death'' that's necessary to cross if you're going
    to go from a promising compound to an FDA application for a
    clinical trial. And we're pursuing that quite vigorously.
        And, Senator, I do understand the pressures on the budget
    system are severe. And I should have said earlier that, in that
    condition, the fact that the President's budget was able to
    come up with a $1 billion increase for NIH is something that--
    we should all, sort of, credit the administration with their
    vision for science. And I, personally, am delighted to see that
    this is an administration that has put science at such a high
    priority, even with frozen discretionary budgets.
        What we could do that the CAN legislation provides is not
    just about money, though, it's also about flexibilities. So,
    what that legislation allows is that some proportion of that
    money can be used in a Defense Advanced Research Projects
    Agency (DARPA) like model, where you have flexible research
    authority to go beyond traditional grants, contracts, and
    cooperative agreements, to manage projects in very forward-
    looking ways. And that, for this kind of science, where you
    need to make decisions quickly, where you need to bring in
    other partners in a quick turnaround when you see you need to
    fill a void in what the science is showing you needs to be
    done, can be quite valuable. And we do not, at the present
    time, have that kind of flexibility for this sort of project.
    And we could benefit from that.

                          FLEXIBLE RESEARCH AUTHORITY

        Senator Harkin. But, Dr. Collins, you have the flexibility,
    now that it's authorized. I know, you have that--what you're
    saying is, you don't have the money.
        Dr. Collins. Well actually, the way the bill was written,
    it says that the flexibilities of this bill may not be utilized
    unless the appropriation is put forward. Some appropriation is
    required before this is activated. So, unless, in the
    appropriations process that you all are thoughtfully leading,
    there is a green light offered to this project by providing
    some kind of funding, I am not permitted to take advantage of
    the authorized flexibilities. That's the way the legislation
    was put together.
        Senator Harkin. Even if we just appropriate a dollar?
        Dr. Collins. A dollar would, I suppose, do it, although it.
    It might be a little hard to do a DARPA program with $1. I
    don't know.
        Senator Harkin. I mean, I'm just talking about the trigger
    mechanism that allows this--you just told me something I didn't
    know. I didn't know that. So, this is very interesting.
        Dr. Collins. And, of course, Senator, the other question
    is, in trying to figure out all of the priorities that I now
    struggle with, How does this fit? And obviously, you might say,
    ``Well, why don't you just do this with the budget you've
    got?'' Well, that would mean I would have to do less of
    something else. And already, with our 15 percent success rates
    looming, you can imagine how much of a stress and strain that
    is.
        Senator Harkin. Dr. Collins, I feel your pain.
        Dr. Collins. I'm sure you do.
        Senator Harkin. That same thing is hitting us here--not
    just here, but in health, education--we're going to have some
    real problems in education, meeting our needs in higher
    education. So, we've just got a lot of things that are pulling
    at us, and we just are not going to have the funds to do it.
    So, we've got to make some pretty tough decisions, too. And
    some of our friends are not going to be very happy with some of
    the decisions that we make, but we're all going to have to
    sharpen our pencils and just try to prioritize things. And what
    I'm hearing about the CAN is--it's a very high priority.
        Dr. Collins. That's correct.
        Senator Harkin. The translational research. And so, I'm
    going to take a look at what you just told me about--that
    there's a trigger mechanism in the legislation.
        I think, Senator Specter, that's something we're going to
    have to take a look at here.
        And I accept your word on that. We'll just have to see how
    much we need to put in there that would trigger that.
        Now, I know Senator Specter would like the full $500
    million. Yes.
        Senator Harkin. Actually, so would I.
        Senator Specter. We could----
        Senator Harkin. I don't have any problem with the $500
    million, but I----
        Senator Specter. We could do more than that. That was the
    appropriation for fiscal year 2010.
        Senator Harkin. Oh----
        Senator Specter. And now it's a set sum, so we could do $1
    billion.
        Senator Harkin. It was $500 million for 2010, such sums
    after that.
        Senator Specter. So, we're now at a set sum, so it could be
    $1 billion or $2 billion.
        Senator Harkin. You tell me where to get the money, and----
        Senator Specter. I will.
        Senator Harkin. Okay. And we'll just put it out there, who
    we're going to take it away from to get that money. Like I
    said, we just have a lot of different demands on our money.
        I had one follow up----
        Senator Specter. Mr. Chairman, you and I have found as much
    as $3.77 billion, in the past. And it was just exactly what you
    mentioned, it was the sharp pencil.
        Senator Harkin. Well, in the past----
        Senator Specter. And there are other accounts which do not
    rate with curing cancer or Parkinson's or Alzheimer's. And you
    and I did it before, and we can do it again.
        Senator Harkin. Yeah, we did it before, when we had some
    budget flexibility. I don't see much of that there right now. I
    just don't. Unless you've got some way of getting it.
        Anyway, I ran up my time. I'm yielding to Senator Specter
    for another round. Do we have another round?
        Senator Specter. No, that's it, Mr. Chairman. That really
    is.
        Well, I have one other item that I would like to take up,
    and that is the funding on minority health.

       NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES (NCMHD)

        Senator Specter. I note that it is in the budget for $219
    million. The health reform bill elevated the NCMHD at NIH to an
    Institute. And the administration requested a budget of $219
    million, which, by comparison, seems low. What do you recommend
    on that, Dr. Collins?
        Dr. Collins. Well, actually, the NCMHD, is a major
    coordinator of minority health and health disparity research at
    NIH, but certainly all of the Institutes are invested in this
    area. If you look at the graph, here on the screen, the total
    investments estimated for 2011, with this budget, would be more
    like $2.7 billion, so more than 10 times what the funding is,
    specifically for that Institute.
        Because we actually think that minority health and health
    disparities ought to be a priority for all of the Institutes.
    Whether it's the NCI or the NHLBI, or the Diabetes Institute,
    these are all areas where health disparities are a critical
    matter.
        Senator Specter. Well, then why was a new Institute
    established for minority health, if it's accommodated at other
    places?
        Dr. Collins. I think there was a desire to have it more
    visible, to have a coordinating function, which that----
        Senator Specter. $219 million doesn't give you a whole lot
    of visibility.
        Dr. Collins. It has provided an opportunity to give
    endowments, for instance, to some of the traditionally
    minority-serving institutions. That's a major part of what that
    Center, and now Institute, has done, when that flexibility
    didn't exist before. And certainly this Institute, every 4
    years, puts forward a strategic plan, which they coordinate, on
    health disparities. And that didn't really have a home before,
    in terms of doing that kind of strategic plan coordination; and
    now it does.
        Senator Specter. Thank you.
        Thank you, Mr. Chairman.

                               BURDEN OF DISEASE

        Senator Harkin. Thanks, Senator Specter.
        Let me follow up on the Alzheimer's thing that I started
    off with on. The first part just had to do with that finding of
    that panel. But, here's the whole issue of how NIH decides how
    much to spend on individual diseases. It's something that keeps
    coming up; year after year, I hear about it.
        First of all, Congress does not earmark funding levels by
    disease. And I hope we never do. As long as I'm chairman, we
    never will.
        I'm often asked, by patients and advocates, for example,
    how to explain the NIH funding level for a disease like
    Alzheimer's.
        As we know, Alzheimer's is an enormous burden on our
    society, not just in human terms, but in terms of our overall
    economy. There's an estimate out there that, from 2010 to 2050,
    the Medicare and Medicaid costs of Alzheimer's will total--
    ready for this one?--about $20 trillion. That's just for the
    care of Alzheimer's. Now, I don't know if that's high or low;
    I'm just tossing this estimate out there. Even if it was half
    that, it would be staggering.
        And yet, if you look at the NIH budget, funding for
    Alzheimer's makes up a much smaller share than one might
    expect; about 1.5 percent.
        Another example: pancreatic cancer is the fourth leading
    cause of cancer-related death, but less than 2 percent of the
    NCI's budget is devoted to this disease.
        So, my question, basically, is this, Dr. Collins. What role
    does the burden of a disease--the burden on society--play in
    where NIH allocates its money?
        Dr. Collins. Senator, it's a great question, and it's a
    question that all of the people who have sat in this chair in
    prior years have also wrestled with. From the very beginning of
    NIH and its system of trying to define how to set priorities,
    there have always been debates about what are the right
    weighting factors to apply to particular diseases. And I would
    say that it's a complicated enough calculus that it'll take a
    minute to explain.
        So, first of all, some of what NIH does needs not to be
    focused on a specific disease; otherwise, we will not have the
    foundational discoveries that result in Nobel Prizes and
    transformative understandings about neuroscience and immunology
    and cell biology and all of those things that are the really
    important foundation upon which everything rests. So, we would
    not want to have our entire budget specifically focused on
    disease research, or we would probably be mortgaging our
    future.
        When it comes to those things that are clearly in need of
    attention, how do we decide? So, this--certainly, the burden of
    disease has to be a big factor, and the cost of that disease
    has to be a big factor. And you've quoted numbers for
    Alzheimer's that are staggering in that regard. And diabetes
    could also be cited in that way--and cancer and heart disease.
        But, if we based our decisions solely on those issues, then
    rare diseases would tend to get ignored, or funded in only the
    very smallest amounts. If a rare disease happens to strike your
    own family, it's hard to say it doesn't matter. For that
    person, the burden of disease is very high. So, we clearly have
    a responsibility there, as well.
        And oftentimes, studying rare diseases gives us insights
    into common diseases. We study progeria, that affects maybe 30
    kids in this country, and we learned something about aging that
    we never knew before, which affects all of us. Those kinds of
    connections keep popping up over and over again. We wouldn't
    have statins if we hadn't started out by studying a rare cause
    of very high cholesterol levels. All of those, I think, are
    reasons not to focus solely on burden of disease.
        And then, there's scientific opportunity, which has got to
    be a big part of this. To say, ``We have a disease problem, and
    we're going to throw money at it,'' if nobody has an idea about
    what to do, is unlikely to be productive.
        And to take another area, which maybe is not quite as much
    of a burden, or quite as much of an expense, but where you can
    see the scientific field is just poised for a breakthrough, you
    don't want to miss that opportunity.
        So, the job of those 27 Institute Directors, and my job, is
    to try to survey the landscape, sort of, weekly, and figure out
    how to do that steering of the ship to try to be sure we are
    investing most wisely. Do we always get it completely right? I
    wouldn't say we could claim that, but I think we do pretty
    well. And we are supported, of course, by this remarkable peer-
    review system. There's two levels which both looks at the
    scientific rigor of a grant proposal and then, at the second
    level, tries to figure out where are the highest program
    priorities, factoring in things like burden of disease. And
    when you look at the landscape of what we do across diseases,
    it doesn't match up precisely with what you might have guessed,
    just based on epidemiology, but I think it's fair to say
    there's a pretty strong connection.
        Alzheimer's--you know, we are working hard on that. There
    are 30 new drugs that are in various stages of being developed
    for this approach, using things that we've learned about the
    amyloid deposits in the brain, and the enzymes that are
    involved in breaking that down, and how to encourage them to do
    a better job.
        Vaccination--we talked about vaccination against nicotine;
    maybe a vaccination against amyloid, for Alzheimer's, which,
    unfortunately, in the early trials, a few years ago, ran into
    some unfortunate side effects. But, people are developing new
    ideas about how to get around that.
        I couldn't agree more that, if there's an area that
    desperately needs a breakthrough, it's Alzheimer's disease. A
    lot of people trying.

                               PANCREATIC CANCER

        Senator Harkin. Again, that gets me to another question
    about causes and the rapid growth of certain diseases. It just
    seems like Alzheimer's is exploding.
        Pancreatic cancer--the huge increase in pancreatic cancer
    in just the last few years. And different medical personnel
    I've talked to about this says that there's something going on
    out there; something is causing this huge increase in
    pancreatic cancer, but no one can quite figure out what it is.
        And so, that's why I say, you need to look at this--I mean,
    it--I'd like to have some sort of satisfaction, or some
    feeling, positive feeling, that NIH is pivoting a little bit on
    this and saying, ``What is causing this? Why?'' and guiding
    some more research into pancreatic cancer and what's happening
    there.
        We always knew that it was one of those secret kinds of
    cancers; in other words, you didn't know about it until it was
    too late----
        Dr. Collins. Yeah.
        Senator Harkin [continuing]. Because there was no markers
    for it or anything. But, it's not only that now, but it's just
    the huge increase. I forget the figure, but it's just up
    tremendously, the number of people being diagnosed with
    pancreatic cancer.
        Do you think NCI is pivoting and looking at this and
    putting more emphasis on it?
        Dr. Collins. I think pancreatic cancer is a cause of major
    concern at NCI, and is for me, personally, when you see the
    number of individuals being diagnosed with this disease, which,
    as you say, often comes to light after it's already too late,
    because it doesn't reveal itself until it's already,
    oftentimes, spread. It is, all too often, a disease that we
    don't do much for, at the present time, except chemotherapy,
    which may gain a few months. And, of course, some notable
    figures--Patrick Swayze, diagnosed with this disease, and the
    way in which that created a new personal face, has brought even
    more attention to this, as well it should.
        So, pancreatic cancer is one of the cancers being pursued
    by the Cancer Genome Atlas. This comprehensive effort to try to
    identify what exactly goes wrong in a pancreatic cell to cause
    it to grow out of control this way, and not just look under the
    lampposts, where we've been looking all along for clues, but
    actually using the tools of genomics to get all the answers
    that--all of the ways that a cell in the pancreas can start to
    go bad. And that will, I am confident, Senator, give us a
    comprehensive ability, both to do a better job of early
    diagnosis, but, most importantly, to identify new therapeutic
    magic bullets that will go to the heart of that cancer, like
    Gleevec does for leukemia; except we need a Gleevec for
    pancreatic cancer, don't we? And the problem right now is, we
    don't know what the target is that we're shooting at. The
    Cancer Genome Atlas will reveal the complete list of targets.
        Of course, that doesn't happen overnight. That's a process.
    And again, the CAN, we talked about a minute ago, may assist,
    once the target's identified, in speeding up the process of
    getting something ready for a clinical trial. All of those
    steps have to be integrated together.
        Again, I think having new leadership, imminently, for the
    NCI, is going to be quite timely in this regard. I am
    impatient, just as you are--frustrated, as you are--about this
    terrible disease of pancreatic cancer, and how many people we
    lose to it, and how impotent we seem to be, so often, in being
    able to stop the course of the disease.
        Senator Harkin. Yes.
        Dr. Collins. And I would not want to have a day go by where
    we were passing up on the opportunity of new ideas to do
    something about this.
        Senator Harkin. Yes, because like B-cell lymphoma and
    things like that, and what NCI has done has been miraculous.
        Dr. Collins. Yes.
        Senator Harkin. The cure rate there is just phenomenal.
        Dr. Collins. Yes.
        Senator Harkin. It's very, very good.
        Dr. Collins. Well, that's a good point, because there you
    have targets, and----
        Senator Harkin. Yes.
        Dr. Collins [continuing]. There, the drugs have developed
    against those targets. And, boy, they work.

                                FDA AND THE NIH

        Senator Harkin. Yes, they sure do. Okay, we'll follow up on
    that.
        You recently joined Secretary Sebelius and FDA Commissioner
    Hamburg in announcing a new partnership between NIH and FDA
    that, again, is intended to speed up the process of turning
    basic scientific discoveries into treatments. Well, what is
    this effort? How does this correlate with CAN? What are the
    goals? Is this different than what we've been talking about?
        Dr. Collins. It's a part of the whole system that needs to
    be coordinated, integrated, optimized. I think it's clear that
    relationships between NIH and FDA have to be really well
    orchestrated in order for all of those complicated steps, in
    going from an idea to having a successful clinical trial, to go
    forward without missteps that cost time and cost money.
        The FDA has enormous challenges in front of them, in terms
    of the way in which the development of therapeutics is
    evolving. The idea that you might, for instance, for cancer,
    need to get to a place where most patients are not being given
    one compound, but maybe two or three, that's targeted
    specifically to their tumor. Because you're going to know, in
    their tumor, exactly what's gone wrong. So, you look at your
    list of drugs, and you pick the combination that you know is
    zeroed in on their problem. Well, how does FDA evaluate a
    clinical trial of thousands of patients, where they aren't all
    taking the same thing? So, they need scientific research
    efforts to prepare them for that.
        The regulatory science that Peggy Hamburg has been talking
    about is exactly what's needed. We, at NIH, agree. Fact, we
    have funded, with FDA, for the first time, a research program
    on regulatory science. We just announced that. We got 59
    letters of intent. There are really interesting things being
    put forward, that the scientific community thinks they could
    offer to help FDA with the things that are coming down the
    pike, as far as regulatory challenges.
        And many academic investigators, if they're getting more
    involved in the development of therapeutics--and the CAN will
    make that happen--they're not familiar with exactly how to do
    this, and there's a risk that they might sort of get very close
    to an FDA application, and then find out they've left out
    something really important, and have to backtrack, and waste
    time and money. So, we have to tighten up those relationships.
        So, Peggy Hamburg and I have been meeting--and since last
    summer--to talk about how to do that. This new leadership
    council, which she and I will cochair, will involve senior
    leadership of both agencies, and will involve many people at
    middle level, so that we could prepare for the opportunities
    that are coming, and not end up in some sort of bureaucratic
    mixup, which would be really heartbreaking to see.
        I think the atmosphere is just right for this.

                               PATIENT ADVOCATES

        Senator Harkin. Tell me about the role of what I would call
    ``patient advocacy groups.'' When you're going out to conduct
    human trials and, as you say, there's always risks when you
    conduct human trials--I think it's important to inform
    patients, from the beginning, help them understand what you're
    going through, in terms of the regulatory end of it. So, I'm
    just wondering when you're setting up this regime of involving
    these patient advocacy groups so that they can be supportive
    because they want to get the human trials out there. I think it
    might be wise to have them involved so that they understand
    what you're doing and that they can be a proponent of it, that
    they can be out in the public, advocating for this and sort of
    acting as a shield for you out there, perhaps, because a lot of
    people don't understand what you might be doing, and these
    groups could help you. So, I hope you'll look at involving them
    in this process.
        Dr. Collins. Senator, I completely agree with you. I think
    there are many heroes, and ``sheroes,'' out there in the
    advocacy organizations----
        Senator Harkin. Yes.
        Dr. Collins [continuing]. Who have remarkable insight into
    what we could do to improve the success of our whole
    enterprise. And we listen to them, with great attentiveness.
    And certainly, with regard to this relationship, we have
    already had some of those informal consultations. And on June
    2, we're holding a public, sort of, town meeting about this new
    NIH-FDA Leadership Council, and asking advocates and other
    members of the public to come forward and tell us what they
    think are the highest-priority matters for this council to
    address.
        Senator Harkin. So, it's an online town meeting?
        Dr. Collins. I think we're web casting it, and it's also,
    certainly, encouraging people to come live and come to the
    microphone.
        Senator Harkin. Ah. Is that going to be out at the campus?
        Dr. Collins. It is.

                                   STEM CELLS

        Senator Harkin. Very good. That's on June 2. Well, I
    appreciate that. I think that would be important.
        Is there anything--oh, yeah, of course. How could I leave
    you without asking about stem cells?
        I wouldn't let this go.
        You recently announced that--as you did, also, in your
    opening statement--that some additional human embryonic stem
    cell lines have been approved for NIH funding, and including
    the line that's been studied more than any other. Again, what's
    the significance of this? How many lines are we up to now? And
    give me some crystal-ball-gazing. Where are we headed?
        Dr. Collins. Thanks for the question, because this is a
    very exciting area of biomedical research.
        There are now 64 human----
        Senator Harkin. Sixty-four?
        Dr. Collins [continuing]. Embryonic stem cell lines that
    have been approved by this NIH process that was stimulated by
    Obama's Executive order and that are up on the NIH registry and
    may now be used by researchers using Federal funds. And that is
    a number that is going to continue to grow. We have more than
    100 additional lines that are in the process of being reviewed.
        The goal, of course, of the review is to be sure that the
    consent process that was utilized for the embryo donors was
    above reproach. We want to be sure that these lines were
    obtained in a way that is entirely open to ethical scrutiny.
    And that is why the NIH has been conducting the reviews of
    those documents before certifying such a line.
        We were very happy to be able to get the materials, just
    about a month ago, on a few of the lines that had been
    particularly heavily used since 2001, when, as you recall,
    President Bush's decision was that lines could not be used that
    were derived after that. But, there were 21 lines that were
    allowed, at that point.
        Senator Harkin. Right.
        Dr. Collins. And there were a couple of them that were used
    particularly heavily. One, called H1, we were able to approve
    right away, because we had the documentation. The one that was
    causing a lot of anxiety in the community is a line called H9,
    and it just took a while for the deriver of that line--
    derivers, because it involved both Israel and the United
    States--to locate all the documents and to get them to us. Once
    we had them, we did a rigorous review, in a very short
    turnaround. We're happy to see that everything was totally in
    order and approved that line. And I think that settled down
    some of the concerns that people had about whether that line
    was still going to be available to them, or not. We had allowed
    researchers to continue to work with it, with an existing
    grant; but, if somebody came back for a competing renewal, we
    wanted them to start working with approved lines. They can now
    use H9 as long as they want; it's fine. And there will be
    hundreds more coming through.
        On top of that, of course, there's great excitement about
    this additional way of making a pluripotent stem cell by taking
    a skin cell and, with just four genes, carefully chosen--and
    this is the remarkable work of Shinya Yamanaka, who I'm sure
    someday ought to win the Nobel Prize--you can take that skin
    cell and turn that into a pluripotent cell that basically can
    make any cell type that you would want it to, if you stimulate
    it with the right cocktail of cytokines and so on. Just
    phenomenal, Senator, that there's this much plasticity in the
    system, and that a cell that's been sitting in your skin all
    those years that--since you were originally born--is capable of
    having that ability. But, I guess it sort of makes sense, from
    a genome perspective; after all, that skin cell has the whole
    genome.
        Senator Harkin. Yes, right.
        Dr. Collins. It just needs to be woken up again and
    encouraged to think that it's young and has all those
    potentials to do everything you could imagine.
        That is an area that is just bursting with potential. We
    are actually starting, on the NIH campus, a special center for
    the so-called induced pluripotent stem cells (iPS)----
        Senator Harkin. Oh.
        Dr. Collins [continuing]. And the specific goal there is to
    push the agenda toward actual clinical applications.
        Senator Harkin. Great.
        Dr. Collins. The beauty of these, if it turns out to be as
    successful as we all hope, is that these are your cells; and
    so, if you were to need them for Parkinson's disease, because
    you develop that, or for a liver problem, you should be able to
    receive that kind of autotransplant, without the rejection
    problems that would otherwise apply if the cells came from
    somebody else. So, that is a big positive about this.
        The questions are safety, particularly, because a
    pluripotent cell sometimes grows when it isn't supposed to. And
    one of the ways we actually characterize pluripotent stem
    cells, like iPS cells or embryonic stem cells, is by whether
    they can make tumors if you put them into----
        Senator Harkin. Oh.
        Dr. Collins [continuing]. A particular mouse model. And
    obviously, we have to be very sure, before we try this in human
    applications, that we're not creating more trouble.
        There is, as you may know, a single FDA-approved trial for
    clinical use of human embryonic stem cells. It's for spinal
    cord injury. It's by a company called Geron. They have not yet
    enrolled their first patient, but expect to later this year.
    Obviously, everyone is watching that, although I think,
    realistically, one should not assume that the very first trial
    of any brand new therapy is going to tell the whole tale about
    its promise.
        But, of all the areas that are going forward right now in
    biomedical research, that I think have been breathtaking in
    their potential, this is right near the top of the list. And I
    think NIH, as you can maybe tell from my remarks, is pretty
    excited about pushing this forward with as much energy and as
    many resources as we're able to.
        Senator Harkin. I'd just ask my staff to get me all the
    information on this spinal cord. I had read about it, know a
    little bit, but I don't have--but, if you can get me some
    information on that, I'd appreciate it.
        Dr. Collins. Happy to do that.
        [Information follows:]

                      Stem Cells for Spinal Cord Injuries

        Geron Corporation is a biotechnology company based in California.
    Its lead human embryonic stem cell (hESC)-based therapeutic candidate,
    GRNOPC1, contains human embryonic stem cell hESC-derived neural support
    cells developed for the treatment of acute spinal cord injury. In pre-
    clinical studies, GRNOPC1 has been demonstrated to repair myelin, a
    protective nerve coating, and to stimulate nerve growth leading to the
    restoration of function in animal models of acute spinal cord injury.
    The initial proof-of-principle animal studies were conducted by Dr.
    Hans Keirstead, an investigator at the University of California, Irvine
    with funding from the National Institute of Neurological Disorders and
    Stroke.
        In January 2009, Geron's Investigational New Drug application for
    GRNOPC1, which application the company had submitted to the U.S. Food
    and Drug Administration (FDA), went into effect. In May 2009, FDA
    placed a hold on the start of the phase 1 clinical trial and requested
    that Geron conduct additional pre-clinical studies to provide further
    assurance of GRNOPC1's safety. Geron has recently reported that
    additional data have been submitted to FDA, and its Web site now
    indicates that phase 1 clinical trials are expected to proceed in the
    third quarter of 2010.
        If Geron's clinical trial is allowed to proceed and GRNOPC1, as the
    subject of a biologics license application, is shown to be safe and
    effective, the therapy may provide a treatment option for thousands of
    patients who suffer severe spinal cord injuries each year.
        http://www.gemcris.od.nih.gov

        Senator Harkin. And the last issue--the last issue of
    Scientific American, which I always call the ``layman's
    magazine of an NIH report''--something I can understand; it's
    my must-reading every month, the Scientific American--but, the
    last cover--get a copy of--it was all on the iPS, on the adult
    stem cells, as they say. And it was a fascinating article about
    turning the clock back. And Dr.--I forget his name.
        Dr. Collins. Yamanaka.

                              SICKLE CELL DISEASE

        Senator Harkin.--Yamanaka, yes--is featured in that, and
    the way it was written is--just makes you think that this could
    be the--the way to go. I don't know. That's why I've always
    been in favor of all stem cell research, whether--whatever it
    is, whatever pathway it leads us down, within the ethical
    guidelines that we've established.
        Dr. Collins. Well, think about sickle cell disease as a
    possible application for iPS. This has already been done in a
    mouse model, which is one of the reasons I think I'm----
        Senator Harkin. Yes.
        Dr. Collins [continuing]. Particularly excited about its
    potential for humans. If you could take somebody with sickle
    cell disease, this terrible disorder, where a hemoglobin
    mutation causes the red cells to clog up in the vessels and
    cause all manner of organ damage and much pain. Take a skin
    cell, make it into an iPS cell, grow up a bunch of those, and
    then, using well-established experimental protocols, convert
    those iPS cells into bone marrow stem cells, and infuse them
    back in, after you've fixed the sickle mutation, which you can
    do while the--you're still working with a iPS cell in a culture
    dish. So, you can kind of do the whole cycle.
        That has been done by Rudy Jaenisch, at MIT, in a mouse
    model, and cured sickle cell disease in the mouse. Now,
    everybody will say, ``We've cured a lot of diseases in mice,''
    and we have. But, by this protocol, it's pretty radical and
    pretty exciting, and certainly--one of the diseases that I hope
    will be high on the list for first human applications will be
    sickle cell. It's a 100 years since that disease was first
    described. This year, 100 years.

                             AUTOLOGOUS STEM CELLS

        Senator Harkin. Amazing. Yes.
        Let me ask you about autologous stem cells. I've been
    meeting somewhat with FDA on this, in terms of a change in
    their approval process that took place in the--in about 2005,
    if I'm not mistaken. And--but, that's another--that's the
    regulatory end. I'm just more interested in the scientific end,
    because I've had people in my office who have had autologous
    stem cell treatment. And--interesting group of people. One was
    a pilot who had been in an airplane crash and was, basically,
    paralyzed from his waist down. And through a process of
    autologous stem cells--I mean, he's not walking like you and I,
    but with canes and crutches. I mean, he's actually walking.
    But, you know, not fully recovered.
        Another person that had some heart problems brought in his
    different PET scans and different things like that, and,
    through autologous stem cells, has never had to have heart
    surgery.
        And there were a few others that I met. But, this is all
    through autologous stem--and some of that's being done in our
    country right now. Some of that's being done.
        Can you enlighten me as to what this involves? And what is
    NIH doing in autologous stem cells?
        Dr. Collins. So, this is an interesting area, and a rather
    controversial one----
        Senator Harkin. Yes, I know.
        Dr. Collins [continuing]. In terms of, what capability
    these autologous stem cells have to home in on the site where
    they're needed and how they actually turn into the kind of
    cells that are needed there in order to compensate for what's
    happened, whether it's a spinal cord injury, whether it's a
    heart attack and you're trying to provide an opportunity to
    repair itself?
        Frankly, the NIH-supported studies on this have not been as
    encouraging as many people had hoped. Take the approach to
    heart attack. Ten years ago, there was a lot of suggestion--
    enthusiasm, here--that bone marrow stem cells might, if given
    directly into the heart muscle after a heart attack, allow
    repair of that area that had suffered damage. And there were
    experiments done in animals that looked encouraging; and human
    trials that were done, in many centers, that had somewhat mixed
    results.
        And I think, now, looking back on that, the evidence that
    that has actually been beneficial is not nearly as convincing
    as one would like.
        That has not stopped, of course, the research from going
    forward. And it shouldn't. And I can't tell you, but I could
    for the record, exactly what the total is--now is, of NIH-
    supported autologous stem cell trials.
        I will say that I've heard some heartbreaking stories of
    people who have gone outside of the United States to undergo
    these kinds of trials, in the hands of people who really are
    not scientifically very rigorous, and bad things have happened,
    in terms of the consequences--infections, stem cells that got
    in the wrong place, people basically spending large sums of
    money for the kinds of therapies that really had no scientific
    basis, in hopes that it would help them.
        So, anybody contemplating that ought to be sort of eyes
    wide open, as far as what the evidence is.
        And we will continue to push this approach. We spend more
    money on adult stem cells than we do on embryonic stem cells,
    because of the potential opportunities there. And obviously,
    there are great successes, particularly bone marrow transplant,
    that we can all point to, that has saved many, many lives. But,
    the broader applications for curing problems that involve solid
    organs, I think, are much more challenging.
        There's a protocol just getting started, not with
    autologous cells, but with fetal cells, to try to treat Lou
    Gehrig's disease, ALS, which is obviously a disease of great
    frustration and great tragedy when it strikes.
        So, these kinds of approaches deserve every bit of
    attention, as long as they're done rigorously and as long as we
    find out, at the end of the study, ``Did it work, or did it
    not?'' so that we can guide people who are interested in that
    outcome.
        Senator Harkin. I'd like to know more about autologous stem
    cells. Get me some information. I'd just like to know, you
    know, what's being done at NIH in research on autologous stem
    cells.
        Dr. Collins. We're happy to provide a summary of that----
        Senator Harkin. Oh, good.
        Dr. Collins [continuing]. For you, Senator.
        [The information follows:]

                             Autologous Stem Cells

        Autologous stem cell transplantation (ASCT) is the use of an
    individual's own stem cells for the treatment of disease. The best
    known application of this technique is commonly referred to as ``bone
    marrow transplantation,'' where an individual's hematopoietic (blood)
    stem cells are harvested and then reintroduced to reconstitute the
    blood and immune system. This form of ASCT has been in use for many
    years, and has demonstrated clinical effectiveness for the treatment of
    several diseases.
        However, the concept of ASCT can be expanded to include stem cells
    harvested from one organ system to treat another organ system. Proof of
    principle animal studies revealed that stem cells harvested from organs
    such as bone marrow, skin, gut or endometrium, may be able to treat
    diseases in or ameliorate damage to solid organs such as the heart,
    brain, or spinal cord. These findings have raised hopes that these
    treatments could be transferred to the clinic and have led to the
    development of a growing cellular therapy industry within the United
    States and abroad. The application of ASCT across organ systems in
    humans is still in early experimental phases, and, unfortunately, the
    controlled studies conducted thus far have demonstrated mixed results,
    with some even having severe negative consequences.
        The National Institutes of Health (NIH) continues to support
    research into the development of safe and effective treatments for
    diseases and disorders using ASCT. I am providing you with a summary of
    NIH-supported clinical trials using autologous stem cells. This summary
    is a broad overview of the many research projects being conducted.
    National Cancer Institute (NCI)
        ASCT is an important treatment option for several hematologic
    cancers as well as other types of cancer and other diseases. In this
    case, a patient's own bone marrow is used as a source of stem cells to
    reconstitute his/her blood cell producing capability following high-
    dose curativeintent chemotherapy. However, ASCT is not curative for all
    patients and NCI continues to support research to refine and improve
    outcomes using ASCT in both intramural and extramural research
    settings. Strategies under investigation include adding novel agents
    and agent combinations following transplant and adding
    immunotherapeutic drugs in conjunction with transplant. These
    strategies are a therapeutic tool in treatment of the following disease
    states (among others): multiple myeloma and other plasma cell disorders
    such as amyloidosis and Waldenstrom's macroglobulinemia; Hodgkin's
    disease and non-Hodgkin's lymphoma; acute myelogenous leukemia and
    acute lymphoblastic leukemia; neuroblastoma; inflammatory breast
    cancer; systemic lupus erythematosus; and leukocyte adhesion
    deficiency.
    National Heart, Lung, and Blood Institute (NHLBI)
        ASCT holds great potential for treating cardiovascular, lung, and
    blood diseases and the development of clinically feasible applications
    is an important part of NHLBI's strategic plan.
        In the cardiovascular area, ASCT is being investigated in phase I/
    II trials for the treatment of damaged or malfunctioning heart muscle,
    and in an upcoming phase I trial for treatment of peripheral artery
    disease. Bone marrow mononuclear cells and mesenchymal cells are being
    tested for treatment of acute myocardial infarction (heart attack) and
    heart failure by injecting stem cells directly into the heart. In
    another study, cardiac-derived progenitor cells, obtained via cardiac
    biopsy, are being tested for treatment of individuals with ischemic
    left ventricular dysfunction. Finally, parent-banked umbilical cord
    blood-derived stem cells will be tested for treatment of limb muscle
    damage by injection into the affected muscle.
        In the hematology area, ASCT has been performed for more than five
    decades. In 2001, NHLBI initiated a network specifically to conduct
    multi-center trials to improve outcomes in blood and marrow
    transplantation, including eight clinical trials involving ASCT.
    Examples include a comparison of cell sources (autologous vs.
    allogeneic), a comparison of conditioning regimens used prior to ASCT,
    and the possible benefit of combining intensive chemotherapy with an
    autologous stem cell transplant. Investigator-initiated studies have
    also been implemented including a long-running program project grant on
    stem cell transplantation.
    National Institute of Allergy and Infectious Diseases (NIAID)
        NIAID researchers are investigating potential opportunities for
    improving immune function in patients with certain rare genetic
    disorders, including X-linked Chronic Granulomatous Disease, X-linked
    severe combined immune deficiency, and WHIMS (warts,
    hypogammaglobulinemia, infection, and myelokathexis syndrome) through
    gene therapy and other treatments targeting human hematopoietic stem
    cells. NIAID also is supporting two trials to assess autologous
    hematopoietic stem cell transplantation ``to reset'' the human immune
    system in patients who suffer from the autoimmune diseases multiple
    sclerosis and systemic sclerosis.
    National Human Genome Research Institute (NHGRI)
        NHGRI is supporting a gene therapy trial for a rare form of
    inherited immunodeficiency called adenosine deaminase (ADA) deficient
    severe combined immunodeficiency (SCID). Eligible children with ADA-
    SCID are admitted to the Clinical Center where their autologous bone
    marrow stem cells are collected and subjected to retroviral-mediated
    gene transfer to correct the genetic defect before being reinfused.
    Results from treated ADA-SCID patients indicate that this approach can
    regenerate immune responses in these severely immune-compromised
    subjects.
    National Center for Research Resources (NCRR)
        NCRR supports ASCT through its General Clinical Research Centers.
    Researchers are investigating the use of ASCT in patients with relapsed
    Hodgkin's or non-Hodgkin's lymphoma. Other scientists are transfusing
    autologous umbilical cord blood to regenerate pancreatic islet insulin-
    producing beta cells and improve blood glucose control is being tested.
    Finally, other researchers are comparing disease-free survival between
    two different clinical protocols for ASCT.
    National Institute of Dental and Craniofacial Research (NIDCR)
        Bone marrow contains a population of stromal stem cells capable of
    regenerating bone and supporting the formation of marrow. NIDCR-
    supported scientists are planning a study that would involve harvesting
    bone marrow from the hip of patients with cranial (skull) defects that
    have failed standard treatments (metal plates, plastic overlays). The
    stromal cells in the marrow will be expanded and then attached to
    ceramic particles and placed into the cranial defects. Patients will be
    monitored to determine if new bone is formed.
    National Institute on Neurological Disorders and Stroke (NINDS)
        NINDS is supporting a clinical protocol that receives biospecimens
    from patients with multiple sclerosis who have received autologous
    hematopoietic stem cells. The NINDS intramural researchers perform
    immunological analysis on the specimens to elucidate mechanisms of
    treatment action.

        Senator Harkin. That'd be good. I'd appreciate that.
        Well, that's good. I enjoyed this session very much.
        As you know, Dr. Collins, I have always, in the past, tried
    to have sessions with each of the Directors of the Institutes.
    However, because of some added responsibilities I have this
    year, now, I--my time is being crunched a lot, and I can't do
    that right now. I am hopeful, though--and I say this for the
    record--that sometime during this year, when I find some space
    opened up a little bit, that I might ask Mr. Fatemi and Ms.
    Taylor to also see if we can pull this together again, where I
    can set up a few days and have three or four down at a time,
    and sit down, because it's very enlightening. It's better than
    reading Scientific American, so, I just want you to know that
    I'm contemplating that. I hope I can do that, at some point yet
    during this calendar year.
        Dr. Collins. All of us at NIH would love that opportunity,
    Senator, and we do appreciate the many heavy loads that you're
    carrying this year, and your strong support of medical
    research.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Harkin. Thank you.
        And congratulations, again, on taking over the reins, and
    we're looking forward to working with you on this terrible
    budget crunch that we have.
        Thanks, Dr. Collins.
        Dr. Collins. Thank you, Senator.
        [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

                                  MEDLINE PLUS

        Question. Dr. Collins, I am pleased at the importance you have
    placed on communicating to the American public about the valuable work
    done at NIH. As you may know, it was this subcommittee that first
    called on the National Institutes of Health (NIH) several years ago to
    start a magazine that would go directly to consumers to help people
    take charge of their health and provide reliable up-to-date information
    directly from the experts at NIH. What can be done to make sure that
    this NIH MedlinePlus magazine and its bilingual counterpart, NIH
    MedlinePlus Salud, gets out to every doctor's office and federally
    funded health center? Do you have the resources to do this?
        Answer. The NIH MedlinePlus magazine is the gold standard of
    reliable, up-to-date health information in plain language and in a
    reader-friendly format. I share your enthusiasm for it and its
    bilingual edition, the NIH MedlinePlus Salud, which is in both Spanish
    and English. As you know, the magazine contains no advertising and is
    produced through a partnership between NIH, particularly National
    Library of Medicine (NLM), and the Friends of the National Library of
    Medicine. The magazine is distributed through community health centers,
    hospital emergency rooms, physicians' offices, libraries, and other
    locations where the public receives health services and health
    information. Specific issues or sections of issues are also used for
    targeted health education and disease prevention campaigns. At its
    current budget level, NLM is able to support printing and distribution
    of an average of 260,000 copies of each issue of the English version.
    To date, private sector support has allowed printing and distribution
    of about 100,000 copies of the Spanish version. Both versions are now
    available online at: http://www.nlm.nih.gov/medlineplus/magazine/.
        To increase distribution of the magazines, we are working to extend
    our partnership to include other Government agencies and private
    organizations that have an interest in supporting the distribution of
    health information from NIH to their respective constituencies and
    audiences. For example, the Peripheral Arterial Disease Coalition and
    the American Diabetes Association supported the distribution of
    additional copies of two 2009 issues. The National Alliance for
    Hispanic Health supported the production and distribution of the first
    two issues of NIH MedlinePlus Salud. The NIH and the NLM will continue
    to encourage partnerships with other public and private organizations
    in an effort to ensure that this publication reaches the widest
    possible audience, every doctor's office, and every federally funded
    health center in America.

                 AMERICAN RECOVERY AND REINVESTMENT ACT (ARRA)

        Question. NIH received $10.4 billion in ARRA--roughly $5 billion a
    year in fiscal years 2009 and 2010. That money is about to run out. How
    do you achieve the softest possible landing in fiscal year 2011? What
    are some of the challenges you will face?
        Answer. The $10.4 billion in ARRA for NIH has resulted in more than
    15,000 grants and contracts to date, with more expected by September
    30, 2010. These funds have served as a catalyst for inspiring
    innovative biomedical research in many areas of science relevant to
    health and disease.
        With regard to ensuring the softest possible landing beyond fiscal
    year 2011, NIH has taken steps to limit reliance on ARRA funding. From
    the outset, we decided to use these funds primarily for one-time
    expenditures, special equipment, construction, innovative grants, and
    special projects, which could either be advanced or completed within 2
    years. NIH also anticipated that some of the ARRA grantees who were
    awarded 2-year grants in fiscal year 2009 would seek continued funding
    in fiscal year 2011. These applications will be among those considered
    in the regular NIH competitive grant review process.
        The nature and pace of science is often unique to each research
    question. We expect a staggered increase in applications over the next
    few years resulting from the completion of the ARRA awards. Success
    rates of applicants may potentially be affected by gradual increases in
    application submission rates. NIH will continue to support applications
    that are rated by peer-reviewers to be meritorious and which address
    the programmatic priorities of the NIH Institutes and Centers.

                               GRANT RESTRICTIONS

        Question. Dr. Collins, in a January 2010 interview in The Chronicle
    of Higher Education, you suggested that universities are ``becoming too
    reliant on NIH money, allowing faculty members to obtain all their
    income from Federal research grants.'' You said that when faculty
    members run multiple research projects at the same time, ``that turns
    that investigator into a grant-writing machine perhaps more than a
    doing-of-science machine.'' You added that any new restrictions on NIH
    grants ``would have to be phased in over a fairly long period of time
    because many universities and faculty members would find that quite
    disruptive.'' What sorts of changes to the NIH grant system are you
    envisioning for the future? Would you favor limits on the number of
    grants scientists could receive simultaneously from NIH? If faculty
    members should not expect to obtain all their income from Federal
    research grants, what other sources could supply the funds?
        Answer. Over the past several years, the NIH has supported an
    increasing number of extramural research projects; ARRA provided
    additional support to expand and accelerate these efforts. In the
    upcoming and future years, we expect to see a higher number of
    applications for extramural awards, which could increase competition
    for the limited resources available. Given this, it simply may not be
    sustainable to have a large number of investigators deriving all or
    most of their salary from NIH grants. But before making any changes to
    our grants policy, we need to carefully explore alternatives and seek
    input from the relevant stakeholder groups and from the subcommittee.
    Any recommended changes would then have to be phased in over a period
    of time, as universities and researchers would find rapid change
    disruptive to the health of the American biomedical research community.
                                     ______

                Questions Submitted by Senator Daniel K. Inouye

                       LOWELL P. WEICKER CONFERENCE ROOM

        Question. I understand that you are considering dedicating a
    conference room in the National Institutes of Health (NIH) Neuroscience
    Research Center to Lowell P. Weicker. I greatly appreciate your
    commitment to preserving the honorable recognition of Governor Weicker
    and respectfully request an update on the status of the dedication of
    the conference room?
        Answer. NIH intends to dedicate a conference room to honor Senator
    Weicker's legacy of contributions to the advancement of human health
    through research. We anticipate the dedication to take place soon after
    the Porter Neuroscience Research Center phase II project is completed.
    The Porter Center, which is being built on the western portion of NIH's
    Bethesda campus with funding from the American Recovery and
    Reinvestment Act (ARRA), is scheduled to be completed in 2013. We will
    keep the Senate apprised of the specific plans for the dedication as
    the building's completion date approaches.

                                NURSING RESEARCH

        Question. Senator Burdick and I were instrumental in the
    establishment of the National Institute for Nursing Research (NINR) and
    for 25 years NINR has been dedicated to improving the health and
    healthcare of Americans through the funding of nursing research and
    research training Since it was established, NINR has focused on
    promoting and improving the health of individuals, families,
    communities, and populations. How does the NIH plan to further expand
    this critical arm of research?
        Answer. NINR supports clinical and basic research that develops
    knowledge to: build the scientific foundation for clinical practice;
    prevent disease and disability; manage and eliminate the symptoms
    caused by illness; enhance end-of-life and palliative care; and train
    the next generation of nurse scientists. In order to expand these vital
    areas of research at NIH, the President's fiscal year 2011 budget
    requests $150,198,000 for NINR, a 3.2 percent increase more than fiscal
    year 2010.
        In fiscal year 2011, NINR will build upon the important scientific
    research advances the Institute has supported more than its 25-year
    history. For example, NINR research in health promotion and disease
    prevention will explore strategies to understand and promote behavioral
    changes in individuals; evaluate health risks within communities; and
    explore biological factors that underlie susceptibility and mediate
    disease risk. To improve quality of life for those with chronic
    illness, NINR will continue to support symptom management research to
    illuminate the biological and behavioral aspects of symptoms such as
    pain, insomnia, and fatigue, and to enhance the ability of patients to
    manage their own conditions. NINR's end-of-life and palliative care
    program supports science to improve the understanding of the needs of
    dying persons, their families, and caregivers by examining such topics
    as the alleviation of symptoms; psychological care; advance directives;
    spirituality; and family decisionmaking. NINR training programs will
    ensure ongoing advancements in science and improvements in health
    through the support and development of an innovative,
    multidisciplinary, and diverse scientific workforce. In addition,
    across all of its research programs, NINR will continue its commitment
    to promoting health equity and eliminating health disparities in at-
    risk and underserved populations through the development of culturally
    appropriate, evidence-based interventions.
        Finally, NINR will continue to support basic and clinical research
    to develop the scientific basis for clinical practice. These efforts
    will promote the translation of research into practice; assess cost-
    effectiveness of clinical interventions; improve the delivery, quality,
    and safety of clinical care; and establish the foundation of evidence-
    based practice. Evidence-based practice is essential to ensuring that
    all Americans receive the highest-quality, most-efficient healthcare.
    It is NINR's emphasis on clinical research that places NINR in a
    position to make major contributions to the NIH Director's goals for
    translating basic research to clinical practice, supporting science to
    enable better healthcare, and reinvigorating the biomedical workforce.

                  ALLIED HEALTH SCHOOLS IN REMOTE COMMUNITIES

        Question. At my request, the University of Hawaii at Hilo
    established the College of Pharmacy. The College of Pharmacy's
    inaugural class of 90 students began in August 2007, will graduate in
    2011, and will hopefully stay in Hawaii to meet the growing demand for
    pharmacists. Historically, Hawaii's youth interested in becoming
    Pharmacists would travel to the mainland for school, and not return. It
    is my vision that the people of Hawaii will have educational
    opportunities in the health professions that will in turn increase
    access to care to residents in rural and underserved communities. Has
    there been any consideration of focusing research efforts on the
    benefit of establishing schools of allied health in remote communities
    to meet the growing needs for healthcare and improve access to care in
    rural America?
        Answer. Allied health education is an important part of the U.S.
    rural healthcare infrastructure. Allied health professionals form a
    vital part of the healthcare infrastructure necessary to support
    ambulatory, pharmacy and institutional primary and preventive care, yet
    the complement of allied health training and subsequent rural practice
    choices are limited. Several studies have highlighted the gross
    deficiencies in the health status of those living in rural areas, as
    well as the disparities in the distribution of health resources. Allied
    health education is offered in approximately 2,000 widely dispersed
    rural locations. Of significance, from a health policy perspective is
    the realization that primary healthcare profession shortage designation
    areas significantly lack allied health training education and
    resources. These concerns have served as a catalyst for the National
    Center on Minority Health and Health Disparities (NCMHD) and other
    Federal partners such as Health Resources and Services Administration
    to develop new directions for rural health research and workforce
    studies.
        Research indicates that targeted expansion of allied health
    training resources in rural underserved areas might improve the
    healthcare infrastructure, enhance access to care, and provide career
    opportunities for residents of rural areas. NCMHD will continue to
    support a rural health research agenda as part of its activities. This
    includes collaborative efforts to address the distribution of allied
    health professions training and workforce distribution, providing
    research infrastructure and capacity for rural-based institutions to
    support allied health education training and meet NIH's goal of
    developing scientific resources for disease prevention. Future research
    will be able to identify the optimal mix of allied health professionals
    necessary to support healthier rural communities.

                             CHRONIC KIDNEY DISEASE

        Question. Hawaii experiences a higher than average rate of Chronic
    Kidney Disease (CKD) with 1 person in 7, compared to a national average
    of 1 person in 9, afflicted with this disease. Among the Asian/Pacific
    Islander (API) population groups, Filipinos have one of the highest
    rates of incidence per capita. National Kidney Foundation of Hawaii in
    2007 it is estimated that of the 156,000 residents with CKD,
    approximately 32 percent are Filipino. Has there been any consideration
    to focusing research efforts on preventing chronic kidney disease among
    the API population groups?
        Answer. The National Kidney Disease Education Program (NKDEP) is an
    initiative of the National Institutes of Health that is designed to
    reduce the morbidity and mortality caused by chronic kidney disease
    (CKD) and its complications. NKDEP works to reduce the burden of CKD
    and focuses its efforts on those communities most affected by the
    disease including African Americans, American Indians, and APIs.
        In 2008, the NKDEP initiated the Community Health Center (CHC)-CKD
    Pilot to identify effective strategies or improving detection and
    treatment of chronic kidney disease in community health centers--
    critical primary care settings for many people at increased risk for
    CKD. The pilot involves a small group of centers in the Northeast that
    work together to design, implement, and monitor performance
    improvements related to CKD. NKDEP is currently developing plans to
    broaden the pilot project nationally and will use data from the pilot
    phase pilot and lessons learned to inform this expansion. CHCs in
    Hawaii would be appropriate participants in this effort.
    Representatives from NKDEP have been in contact with Hawaii State
    Representatives and the Hawaii National Kidney Foundation since March
    2008 and have provided technical assistance on how NIH resources could
    potentially be utilized to reduce the burden of chronic kidney disease
    among Hawaiians.

                                  HEPATITIS B

        Question. Hepatitis B and liver cancer, as caused by the hepatitis
    B virus (HBV), are the single greatest health disparities affecting the
    API populations in the United States. While up to 14 percent of the API
    population is infected with HBV, only 0.4 percent of the Caucasian-
    American population is infected. Asian Americans, native Hawaiians, and
    APIs comprise more than half of the 2 million estimated HBV carriers in
    the United States and consequently have the highest rate of liver
    cancer among all ethnic groups. Has there been any consideration of
    focusing research efforts on preventing HBV in APIs and other groups
    disproportionately affected by HBV?
        Answer. The NIH supports research and education activities focusing
    on groups that are disproportionately affected by HBV. For example, the
    multi-center Hepatitis B Research Network, established in 2008, aims to
    advance understanding of disease processes and natural history, as well
    as to develop effective approaches to treating and controlling HBV. The
    network includes 21 clinical sites across the United States, including
    Hawaii, and a central data coordinating center. The network's centers
    are in the final stages of planning several clinical trials in both
    adults and children. Recognizing the health disparities affecting the
    API populations, the network plans to conduct trials testing antiviral
    therapy in these particularly at-risk groups. In another at-risk
    population, the NIH is conducting studies on the use of antiviral
    therapy during pregnancy to prevent the spread of HBV from a
    chronically infected mother to her newborn. The network will enroll
    pregnant women with HBV into clinical studies to assess risk factors
    associated with reduction in maternal-infant transmission.
        Research to develop new classes of drugs that are safe and
    effective in treating HBV infections is essential to effectively
    addressing HBV disparities. It is also critical to study how HBV
    develops resistance to new classes of drugs. For example, in studies
    conducted in nonhuman primates, NIH scientists and their colleagues
    determined that the replication rate for HBV is higher than previously
    thought. A higher replication rate increases the frequency of HBV
    genetic mutations, including those mutations that cause the virus to
    become resistant to drugs. This finding may help enhance the ability to
    predict when HBV virus will develop drug resistance which, in turn,
    will inform the use of existing antiviral therapies, including the use
    of a single antiviral drug versus combination therapies. NIH-funded
    researchers also discovered that selective combinations of existing
    drugs (nucleotides and nucleosides) may work better together not only
    to inhibit the emergence of mutated strains, but also to do a better
    job of reducing circulating virus.
        A workshop, arranged by NIH together with the U.S.-Japan
    Cooperative Medical Sciences Program and the Asia Pacific Association
    for the Study of Liver, was held in Hong Kong in February 2009. Its
    purpose was to understand the issues related to antiviral drug
    resistance encountered in the treatment of HBV infected patients in the
    countries of the Asia-Pacific region. Issues discussed included
    determining the extent and burden of resistance in Southeast Asia,
    which has the highest prevalence and incidence of HBV infection
    worldwide. Other issues discussed were the need for databases to
    catalogue and track virus mutations associated with resistance; to
    track patient management; and to study correlations between treatment
    and clinical outcome.
        Other NIH-supported basic and clinical research holds promise for
    populations disproportionately affected by HBV. For example, currently
    licensed antiviral drugs for HBV target a single step in the viral
    replication cycle. As resistance with this class of drugs seems
    inevitable, NIH-supported investigators, through partnership
    initiatives and investigator-initiated proposals, are redirecting their
    research to novel targets in the replication cycle and are pursuing the
    development of different classes of drugs. Other studies are ongoing to
    explore host responses to HBV infection, how the virus spreads in the
    liver, the influence of viral inoculum on outcome, and the cascade of
    host responses leading to chronicity or resolution.
        There are ongoing efforts to promote coordination and planning of
    all HBV research within NIH and across the Department of Health and
    Human Services. Strategic plans, such as the trans-NIH Action Plan for
    Liver Disease Research (http://liverplan.niddk.nih.gov) and the plan
    produced by the National Commission on Digestive Diseases (http://
    NCDD.niddk.nih.gov), were developed with trans-NIH and trans-DHHS
    input, and highlight important research goals relevant to controlling
    HBV. In 2008, NIH convened a Consensus Development Conference on the
    Management of Hepatitis B. The conclusions of this conference can be
    found at the following Web site: (http://consensus.nih.gov/2008/
    hepbstatement.htm). The NIH is also providing expert input on the HHS
    Viral Hepatitis Interagency Working Group to coordinate the responses
    to the challenges described in the recent Institute of Medicine report
    on HBV and liver cancer.
        In addition to research activities, the National Digestive Diseases
    Information Clearinghouse provides educational materials for the public
    on HBV to improve knowledge and awareness (available at: http://
    digestive.niddk.nih.gov/diseases/pubs/hepatitis/index.htm). Materials
    on HBV are available in several languages, which include Chinese,
    Korean, Vietnamese, and Tagalog. There is a new series of fact sheets
    focusing on hepatitis B-related issues affecting API.

                                    DIABETES

        Question. One of the gravest threats to the healthcare system is
    the chronic disease of diabetes with its impact on both the economy and
    on the quality of life for nearly 24 million Americans. In Hawaii,
    Native Hawaiians have more than twice the rate of diabetes as Whites
    and are more than 5.7 times as likely as Whites living in Hawaii to die
    from diabetes. Education and prevention are essential to controlling
    this serious, costly, and deadly disease. What innovative research
    efforts have been considered to improve diabetes outcomes and prevent
    diabetes?
        Answer. NIH research has helped to significantly increase the life
    expectancy of people with diabetes and led to the development of a
    proven method to help prevent or delay the most common form of the
    disease, type 2 diabetes. For example, the landmark Diabetes Prevention
    Program (DPP) clinical trial demonstrated that a lifestyle intervention
    aimed at modest weight loss achieved a 58 percent reduction in diabetes
    rates among people at risk in a 3-year trial. The intervention was
    effective in both men and women and in all ethnic groups tested and was
    especially effective in older participants. Results published since the
    original findings have shown that the intervention remains effective
    for at least 10 years. In addition to reducing rates of diabetes, the
    intervention also led to improved blood pressure and lipid levels with
    less use of medications. The study included a site in Hawaii.
        To develop lower cost methods to deliver the DPP intervention to
    the 57 million Americans with pre-diabetes who could benefit, the NIH
    has vigorously pursued DPP translational research. One innovative NIH
    sponsored study tested a group lifestyle intervention, modeled after
    the DPP's, that is delivered at YMCAs. This approach yields a sharp
    reduction of cost per patient, and appears to be achieving excellent
    interim results. Importantly, YMCAs are located throughout the United
    States, including in many communities at high risk of type 2 diabetes.
    For example, the State of Hawaii is home to 17 YMCA branches. A fully
    national implementation of these methods would have the potential to
    affect diabetes treatment for Native Hawaiians in significant ways.
    Because of the excellent results achieved in this program to date, the
    Centers for Disease Control and Prevention (CDC) is planning to expand
    it to 10 more YMCA locations around the country. Similarly, the United
    Health Group, a private insurer, has announced plans to pay for its
    subscribers in six cities who are at risk of diabetes to receive at no
    charge a YMCA-based diabetes prevention intervention modeled on the
    program. These are outstanding examples of the adoption of evidence-
    based prevention methods to alleviate a serious national healthcare
    problem.
        The National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) is also sponsoring a major multi-center trial to study
    the effects of lifestyle change and weight loss on the course of type 2
    diabetes. Exciting preliminary results at 4 years have shown improved
    diabetes control and reductions in cardiovascular disease risk factors
    despite less use of medication. As with the DPP, the study includes a
    substantial representation of minority groups disproportionately
    affected by type 2 diabetes. To build on the findings from major NIH-
    supported trials that have transformed diabetes care by establishing
    therapies that reduce diabetes complications and premature mortality,
    ongoing studies are examining translation of these approaches into
    communities at risk. One such research effort is employing community
    health workers in American Samoa, where diabetes rates are 3-fold
    higher than in the U.S. mainland, to test methods for delivering care
    there, as informed by results from previous NIH studies.
        It is particularly important to understand how diabetes is
    affecting children in America. The SEARCH for Diabetes in Youth study,
    a joint program of the CDC and the NIH, is collecting data on the
    incidence and prevalence of type 1 and type 2 diabetes in young people
    of diverse ethnicity, and thus is providing information to better
    understand the diabetes disparity among young APIs as well as other
    groups. One SEARCH center, located at the Kuakini Medical Center in
    Honolulu, will help provide the most accurate statistics to date on
    childhood diabetes in Hawaii. The National Diabetes Education Program
    (www.ndep.nih.gov), another joint effort of NIH and CDC, distributes
    educational materials conveying the vital health messages that have
    come from the major NIH-sponsored diabetes studies. Many of these
    materials have been translated into a wide array of languages,
    including the Pacific Island languages of Chamorro, Tagalog, Tongan,
    Chuukese, and Samoan, as well as Japanese, Indonesian, and other
    languages of the Pacific Rim. These programs are helping to extend the
    benefit of NIH diabetes research to people of diverse ethnicity in the
    United States and throughout the world.

                         COLLABORATIVE CANCER RESEARCH

        Question. What is the status of the administrations' efforts to
    continue collaborative cancer research and program efforts focused on
    reducing cancer health disparities in native Hawaiians?
        Answer. The administration's efforts to continue collaborative
    cancer research and program efforts focused on reducing cancer health
    disparities in Native Hawaiians are exemplified in a number of
    community-based participatory research programs supported by the Center
    to Reduce Cancer Health Disparities of the National Cancer Institute
    (NCl/CRCHD). These include:

    Community Networks Program (CNP)
        This program was recently renewed and the new CNP centers
    initiative (RFA-CA-09-032) extends the previous efforts of NCI to
    support community-based participatory research (CBPR) in racial and
    ethnic minorities and other underserved populations. The goals of the
    CNP Centers are (1) to develop and perform evidence-based intervention
    research to increase use of beneficial biomedical and behavioral
    procedures for cancer prevention, detection and treatment, which may
    include related co-morbid conditions; and (2) to train and promote the
    development of a critical mass of competitive new researchers using
    CBPR to reduce health disparities. This program and its predecessors
    have promoted and continue to promote CBPR-based cancer health
    disparities research. As part of the current NCl/CRCHD CNP, NCI
    supports two projects aimed at reducing cancer health disparities in
    native Hawaiian populations.
        The 'Imi Hale Native Hawaiian Cancer Network is aimed at reducing
    cancer incidence and mortality among native Hawaiians by maintaining
    and expanding an infrastructure that: (1) promotes cancer awareness
    within native Hawaiian communities; (2) provides education and training
    to develop native Hawaiian researchers; and (3) facilitates research
    that aims to reduce cancer health disparities experienced by native
    Hawaiians. 'Imi Hale is housed at Papa Ola Lkahi, a nonprofit native
    Hawaiian community-based agency in Honolulu, is dedicated to improving
    native Hawaiian health and well being. They collaborate with key
    partners at the community, State, and national levels. Examples of
    clinical partners are the five Native
        Hawaiian Health Care Systems (NHHCS, providing access and
    prevention services to Native Hawaiians on the State's seven inhabited
    islands), the Queen's Medical Center, and Breast and Cervical Cancer
    Control Program. Examples of program partners include CIS, ACS, and
    Hawaii Primary Care Association. Examples of educational and research
    partners include the University of Hawaii, Oregon Health and Sciences
    University, and the NHHCS IRB.
        Weaving an Islander Network for Cancer Awareness, Research, and
    Training (WINCART) is a community-academic consortium employing CBPR to
    reduce preventable cancer incidence and mortality among five API
    communities in southern California. The specific aims of WINCART are
    to: (1) identify individual, community, and health service barriers to
    cancer control among APIs; (2) improve access to and utilization of
    existing cancer prevention and control services; (3) facilitate the
    development, implementation, and evaluation of community-based
    participatory research studies; (4) create opportunities to increase
    the number of well-trained API researchers through training,
    mentorship, and participatory research projects; (5) sustain community-
    based education, training, and research activities by increasing
    partnerships with governmental and community agencies, funders, and
    policy makers; and (6) disseminate research findings to aid in the
    reduction of cancer health disparities for APIs. Project methods
    include implementation and evaluation of community awareness activities
    in each API population; conducting cancer prevention and control
    research; and recruitment/training/mentorship of API researchers.
    Basic Research in Cancer Health Disparities (R21/U01)
        Two new NCI-supported funding opportunities, PAR09-160 and PAR09-
    161, have been developed to encourage basic research studies to
    determine whether there are biological causes and mechanisms of cancer
    health disparities and support the development of a nationwide cohort
    of scientists with a high level of basic research expertise in cancer
    health disparities research. PAR09-160 will focus on the development of
    resources and tools, such as racial/ethnic specific biospecimens, cell
    lines and methods that are necessary to conduct basic research in
    cancer health disparities. PAR09-161 will provide an avenue for entry
    into cancer disparities research through collaboration and association
    with researchers with specific expertise in emerging technologies in
    cancer research.
    Minority Institution/Cancer Center Partnership (MI/CCP)
        The MI/CCP program supports a partnership program that promotes
    research in cancer health disparities. The University of Guam (UOG),
    and the Cancer Research Center of Hawaii (CRCH), an NCI-designated
    cancer center at the University of Hawaii at Manoa, have been engaged
    in a unique and successful partnership over the past 6 years to
    establish a Cancer Research Center of Guam on the campus of UOG, to
    increase number of faculty and students engaged in cancer research at
    UOG, and to increase the number of faculty from CRCH addressing issues
    of particular relevance for cancer health disparities in the Hawaii/
    Pacific region.

                               CANCER PREVENTION

        Question. How will the NIH continue to support an infrastructure
    that has identified and mentored more native Hawaiian researchers in
    cancer prevention and control than any other institution has done in
    the past 20 years?
        Answer. NIH is committed to enhancing workforce diversity within
    the research enterprise, and as part of that effort, seeks to support
    infrastructures that recruit and retain a strong cadre of competitive
    researchers from diverse backgrounds working in cancer prevention and
    control. Within NCI, there are a number of current activities that will
    continue to support an infrastructure to train and mentor native
    Hawaiian and other Pacific island cancer researchers. Examples of
    programs within NCI's CRCHD that support training infrastructure for
    native Hawaiians include:
    MI/CCP
        The NCl/CRCHD supports a partnership program between minority
    serving institution partners and a NCI-designated cancer center to
    foster training and research activities. For example, the newly awarded
    5-year U54 University of Guam and the University of Hawaii at Manoa MI/
    CCP partnership has a well-established infrastructure for mentoring of
    Hawaiian and Guamanian researchers in cancer research as part of their
    diversity training program.
    CNP
        The goal of the NCl/CNP program is to develop and increase capacity
    building in support of community-based participatory education,
    research and training to reduce cancer health disparities. The program
    has increased the development of a cadre of new investigators,
    including among native Hawaiian researchers, in the field of cancer
    health disparities research. To date, a total of 34 native Hawaiians
    have been trained, representing 7 percent of the total CNP trainees.
    The CNP native Hawaiian trainees have submitted 40 grant applications
    and a total of 12 were funded for a 30 percent success rate. Building
    on the success of the CNP program, the new 5-year CNP centers program
    has been established, and will continue to support infrastructure for
    diversity training.
    Promote Workforce Diversity (PAR-09-162)
        The Exploratory Grant Award to Promote Workforce Diversity in Basic
    Cancer Research (PAR-09-162) supports under-represented minorities,
    such as native Hawaiians, in basic cancer research. Through this
    funding opportunity, NCI encourages institutions to diversify their
    faculty populations, and increase the participation of individuals
    currently under-represented in basic cancer research, such as
    individuals from under-represented racial and ethnic groups,
    individuals with disabilities, and individuals from socially,
    culturally, economically, or educationally disadvantaged backgrounds
    that have inhibited their ability to pursue a career in health-related
    research.
    Continuing Umbrella of Research Experiences (CURE)
        The ongoing CURE program offers unique training and career
    development opportunities to enhance diversity in cancer and cancer
    health disparities research. With a focus on broadening the cadre of
    under-represented investigators engaging in cancer research, the
    ongoing CURE program identifies promising candidates from high school
    through junior investigator levels and provides them with a continuum
    of competitive funding opportunities. Today, there are 30 CURE
    supported trainees and 14 high school and undergraduate students who
    are native Hawaiians.
    Diversity Supplements
        These diversity supplements are designed to foster diversity in the
    research workforce. These supplements support and recruit students,
    postdoctoral, and eligible investigators from groups shown to be under-
    represented in biomedical research. Currently, two native Hawaiian
    junior investigators are supported by diversity supplements.
    NCI Community Center Centers Program (NCCCP)
        The NCCCP is designed to create a community-based cancer center
    network to support basic, clinical, and population-based research
    initiatives, addressing the full cancer care continuum--from
    prevention, screening, diagnosis, treatment, and survivorship through
    end-of-life care. The NCCCP pilot has added the Queen's Medical Center,
    Honolulu, Hawaii (The Queen's Cancer Center) to its 30-hospital
    network.
    Cancer Health Disparities Geographic Management Program (GMaP)
        GMaP, a new initiative, is developing transdisciplinary regional
    networks dedicated to the coordination and support of cancer health
    disparities research training and outreach using regional management
    approach. Creating sustainable partnerships among institutions and
    agencies involved in cancer health disparities research and cancer
    care, this initiative seeks to advance cancer health disparities,
    diversity training and ultimately, contribute to disparities reduction.
    A companion program, the Biospecimen/biobanking Management Program,
    will support research and training infrastructure specific to
    biospecimen collections among under-represented populations across the
    country.

                                CANCER RESEARCH

        Question. How will NCI support entities like 'Imi Hale, who engage
    Hawaiian communities in identifying and addressing cancer health
    disparities and invest in building community capacity to mobilize local
    resources and train local staff? The mission of the NCI CRCHD is to
    reduce the unequal burden of cancer in our society and train the next
    generation of competitive researchers in cancer and cancer health
    disparities research.
        Answer. The NCI's CRCHD coordinates multiple programs that focus on
    community based participatory cancer disparities research and multi-
    institution collaborations to reduce the unequal burden of cancer and
    train the next generation of competitive cancer researchers. These
    programs include CNP, Patient Navigation Research Program (PNRP), MI/
    CCP, and CURE. All of the following programs are either in Hawaii or
    extend to native Hawaiians and address cancer health disparities and
    community building among Hawaiian communities.
    CNP
        The NCl/CRCHD CNP builds capacity in community-based participatory
    research, educational outreach, and professional training through
    partnerships with community organizations and institutions working with
    multiple racial/ethnic and underserved populations, including Hawaiian
    populations. The goal of the program is to improve access to beneficial
    cancer interventions and treatment in communities experiencing
    significant cancer health disparities. Currently, the NCI is supporting
    25 CNP projects developing programs to increase the use of cancer
    interventions in underserved communities. Interventions include proven
    approaches including smoking cessation, increasing healthy eating and
    physical activity, and early detection and treatment of breast,
    cervical, and colorectal cancers.
        Each CNP has put together an advisory group that serves as the
    ``voice of the community.'' These advisory groups work with local
    community members to gather information and then deliver back results.
    A steering committee of community-based leaders, researchers,
    clinicians and public health professionals provides additional support.
        To sustain successful efforts in their communities, CNP grantees
    work closely with policymakers and nongovernmental funding sources.
    Together, CNP grantees and NCI train investigators, identify potential
    research opportunities, and work to ensure that best practice models
    are widely disseminated.
    MI/CCP
        MI/CCP is designed to: (1) increase Minority Serving Institutions
    participation in cancer research and research training and (2) increase
    the involvement and effectiveness of NCI-designated Cancer Centers in
    developing effective research, education, and outreach programs to
    encourage diversity among competitive researchers and reduce cancer
    health disparities. These partnerships foster and support intensive
    collaborations to develop stronger cancer programs aimed at
    understanding the reasons behind significant cancer health disparities
    among racial and ethnic minority and socioeconomically disadvantaged
    populations. NCI supports grants under this program that establish such
    a partnership program in Hawaii.
        The NCl/CRCHD supports a partnership program with UOG and CRCH, an
    NCI-designated cancer center at the University of Hawaii at Manoa.
    Engaged in a unique and successful partnership over the past 6 years,
    this program has established a Cancer Research Center of Guam on the
    campus of UOG to (1) increase the number of faculty and students
    engaged in cancer research at UOG; (2) increase the number of minority
    scientists of API ancestry engaged in cancer research, and providing
    pertinent undergraduate, graduate, and postgraduate education and
    training opportunities for API students; (3) further strengthen the
    research focus at CRCH on cancer health disparities with particular
    emphasis on aspects of particular relevance for the people of Hawaii
    and the Pacific; and (4) enhance the awareness of cancer and cancer
    prevention and, ultimately, to reduce the impact of cancer on the
    population in the Territory of Guam, the other U.S.-associated Pacific
    island territories, and Hawaii.
    CURE
        The CURE program is a strategic approach for training a diverse
    generation of competitive cancer researchers. The CURE provides
    educational support to students and junior investigators from high
    school through postdoctoral studies and mentors them in the early
    phases of their careers in cancer research. This approach builds on the
    success of the research supplements to promote diversity and
    strategically addresses each level of the biomedical research and
    education pipeline to increase the pool of researchers from underserved
    populations. There are currently 14 high school and undergraduate
    students being supported by a CURE supplement in Hawaii.
    Diversity Supplements
        These research supplements are designed to foster diversity in the
    research workforce. They support and recruit students, postdoctoral,
    and eligible investigators from groups shown to be under-represented in
    biomedical research. There are currently two junior investigators being
    supported by diversity supplements in Hawaii.
    NCCCP
        Another program within NCI addressing health disparities is the
    NCCCP program. The NCCCP is designed to create a community-based cancer
    center network to support basic, clinical and population-based research
    initiatives, addressing the full cancer care continuum--from
    prevention, screening, diagnosis, treatment, and survivorship through
    end-of-life care. The NCCCP has seven major focus areas to: (1) improve
    access to cancer screening, treatment, and research; (2) improve
    quality of care at community hospitals; (3) increase participation in
    clinical trials; (4) enhance cancer survivorship and palliative care
    services; (5) participate in biospecimen research initiatives to
    support personalized medicine; (6) expand use of electronic health
    records and connect to cancer research data network; and (7) enhance
    cancer advocacy.
        Reducing and eliminating cancer disparities continues to be a major
    commitment for NCI, the research community, healthcare providers and
    policymakers. In recent years, the cancer research community has also
    begun to focus on understanding why members of some population groups
    experience higher cancer incidence and mortality rates than others.

                                CANCER RESEARCH

        Question. Hawaiian researchers have been very effective in
    addressing the unequal burden of cancer among native Hawaiians; however
    Hawaiian researchers are not equally represented in the researcher
    pool. How will the administration demonstrate its long-term commitment
    to programs like 'Imi Hale that address disparities at all levels and
    identify, mentor, and provide research training, fellowships and grant
    opportunities to native Hawaiians interested in cancer research?
        Answer. The NIH continues to promote its diversity programs to
    under-represented individuals at the college, graduate school,
    postdoctoral, and faculty stages of a scientist's career. Native
    Hawaiians are a key target group within these programs. Examining NIH's
    efforts in its formal research training programs at the pre- and
    postdoctoral levels, the most recent data from 2007 are encouraging
    regarding native Hawaiians and APIs. They show that 4 percent of NIH
    trainees self-identified as native Hawaiian and APIs, which is higher
    than the proportion of this group in the total U.S. population.
        The challenge is to retain and sustain these individuals as they
    transition into their independent research careers. NIH has several key
    programs in place that are aimed at addressing this challenge.
    Specifically, CNP (http://grants.nih.gov/grants/guide/rfa-files/rfa-ca-
    09-032.html) is designed to support community-based participatory
    research in underserved populations and provide a training venue for
    preparing a new cadre of scientists to address health disparities
    research. Second, new initiatives in research in cancer health
    disparities (http://grants.nih.gov/grants/guide/pafiles/PAR-09-160.html
    and http://grants.nih.gov/grants/guide/pa-files/PAR-09-161.html) are
    also designed to provide a venue for young scientists to prepare for
    careers in health disparities research. MI/CCP between the University
    of Hawaii and UOG, and community-based programs, including the 'Imi
    Hale Native Hawaiian Cancer Network supported by the NCI, are dedicated
    to health disparities research in the Hawaii and Pacific region.
        Finally, native Hawaiians and APIs are encouraged to apply for the
    Diversity Supplement to Research Grants Program (http://grants.nih.gov/
    grants/guide/pa-files/PA0908190.html) both on the Mainland and in
    Hawaii. This program has supported more than 500 APIs at stages of
    their careers ranging from college education to faculty research
    scientists. NIH intends to continue its support for all of these
    programs.

                                  TUBERCULOSIS

        Question. Dr. Collins, thank you for your continuing leadership on
    biomedical research issues. I would like to turn for a moment to
    tuberculosis (TB), one of the oldest diseases known to mankind. As you
    know, TB continues to impact millions of people around the world,
    including in my home State of Hawaii, which has the highest rates of TB
    in the Nation: 128 cases in 2008 or a rate of 9.6 per 100,000
    Hawaiians. Further, complicating this already serious situation is the
    20 percent increase Hawaii has experienced in the more difficult and
    expensive to treat multidrug resistant forms of TB, in part because of
    the decades that have passed since new treatments have been developed.
    Could you give me an overview of the research initiatives NIH is
    currently undertaking to address the drug resistant forms of TB.
        Answer. TB research at NIH is primarily conducted and supported by
    the National Institute of Allergy and Infectious Diseases (NIAID).
    Through grants and other mechanisms and through its intramural research
    program, NIAID supports a globally relevant TB research agenda. NIAID
    TB research is focused on all aspects of TB, including drug-susceptible
    and drug-resistant TB, as well as TB in HIV co-infected persons. NIAID-
    sponsored basic TB research includes studies to better understand the
    biology of TB and the host-pathogen interaction, including latent TB
    infection in human hosts and in animal models of infection and disease.
    NIAID-supported translational and clinical research is focused on the
    identification and development of new diagnostics, drugs, and vaccines.
    To better understand TB in special populations, NIAID's research agenda
    includes studies of TB in children and immune suppressed persons as
    well as studies to clarify the interaction of HIV and TB to improve TB
    prevention and treatment. To date, NIAID's investment in basic,
    translational, and clinical science has led to the development of
    several new candidate TB drugs, diagnostics, and vaccines. In addition,
    the NIAID developed a research agenda in fiscal year 2008, the NIAID
    Research Agenda for Multidrug-Resistant and Extensively Drug-Resistant
    Tuberculosis (MDR/XDR-TB), to complement and leverage ongoing efforts
    and focus on specific research gaps for MDR/XDRTB.
        Specific NIAID research activities include the following:
        Research on the pharmacological basis of drug resistance in
    infectious diseases.
      --Studies to characterize drug-resistant TB strains, their
            epidemiology and their impact on disease progression, host
            immune response, and response to therapy.
      --An initiative in fiscal year 2010 to support targeted clinical
            trials to evaluate and improve the optimal use of currently
            existing therapies for TB and support for phase I clinical
            studies of new TB drug candidates.
      --Intramural and extramural studies of a multitude of international
            basic science, translational, diagnostic, and clinical research
            activities to better characterize drug-resistant TB and gain
            insight into what specific healthcare interventions need to be
            developed to combat and prevent drug-resistant TB.
      --Collaborations with the HIV/AIDS clinical trials networks to expand
            studies of drug- sensitive and drug-resistant TB as a co-
            infection in patients with HIV/AIDS, enhance the capacity for
            international clinical trials on TB, and increase efforts to
            combat the co-epidemics of TB and HIV.
      --An intramural research program project at the South Korean Masan
            National Tuberculosis Hospital, which cares for the largest
            population of MDR-TB inpatients in the world, to study the
            natural history of MDR-TB and the occurrence of extensively
            drug-resistant TB (XDR-TB) in patients who have completely
            failed chemotherapy.
      --Coordination of drug-sensitive and drug-resistant TB research
            activities with other Federal agencies through the U.S. TB Task
            Force, as well as with other Government and nongovernmental
            organizations such as the WHO/Stop TB Partnership, programs
            funded by the Bill & Melinda Gates Foundation, and not-for-
            profit product development partnerships.

                    UNDER-REPRESENTED BIOMEDICAL RESEARCHERS

        Question. For the past 19 years, the Distance Learning Center has
    been pioneering a new training paradigm, the STEMPREP Project, to
    create the next generation of researchers from native Hawaiian and
    other under-represented minority students. The project provides an
    earlier start in the training pipeline (7th grade) to a national pool
    of minority child prodigies who desire a career in STEM and medicine.
    As we continue our efforts to reduce and ultimately eliminate the
    racial and ethnic health disparities that plague our healthcare system,
    we must support a generation of physician scientists and researchers
    who have the skills to develop sound public health solutions and
    advance public health through scientific discovery. How will the
    administration demonstrate its commitment to programs like the
    Physician Scientist Training Program that has called for an increase in
    the supply of biomedical researchers from under-represented racial and
    ethnic minority populations?
        Answer. The NIH has a history of creating and supporting policies
    and programs with the goal of promoting and providing a diverse
    workforce in the biomedical, behavioral, clinical, and social sciences.
    NIH programs are designed to recruit, train, retain, and develop the
    careers of under-represented individuals, and every NIH research
    training, fellowship, career development, and research education
    project award Funding Opportunity Announcement explicitly States this
    policy. A number of programs target talented science undergraduates by
    providing funds for their college tuition and a stipend for living
    expenses to promote their pursuit of a career in biomedicine. At the
    doctoral level of education, the NIH awards fellowships, traineeships,
    and research grant supplements to individuals in support of their
    studies toward the research doctorate degree. At the postdoctoral
    level, NIH offers fellowships, career development, and research grant
    supplements to promote the transition of young scientists to
    independent investigators.
        In terms of a commitment to providing a diverse workforce in the
    future, the NIH continues to evaluate and explore new and creative
    programs to promote a diverse workforce. Most recently, the NIH has
    committed ARRA funds to support the NIH Director's Pathfinder Award to
    Promote Diversity in the Scientific Workforce (DP4) which was announced
    on March 5, 2010. This new research grant program encourages
    exceptionally creative individual scientists to develop highly
    innovative approaches for promoting diversity within the biomedical
    research workforce. The proposed research must reflect ideas
    substantially different from those already being pursued or apply
    existing research designs in new and innovative ways to unambiguously
    identify factors that will improve the retention of students, postdocs
    and faculty from diverse backgrounds in the workforce (http://
    grants.nih.gov/grants/guide/rfa-files/RFA-OD-10-013.html).
        New studies and grant programs are also underway to identify
    barriers to under-represented individuals being incorporated into the
    biomedical workforce and to more effectively address those barriers.
    The National Institute of General Medical Sciences has launched two new
    research grant programs to explore the development of new interventions
    to improve diversity (http://grants.nih.gov/grants/guide/rfa-files/RFA-
    GM-10-008.html and http://grants.nih.gov/grants/guide/rfa-files/RFA-GM-
    09-011.html).
        In addition, the Office of the Director is undertaking studies to
    more explicitly identify attrition points along the pathway between
    high school and achieving independence as a biomedical scientist.
    Relating this information to variables such as race, ethnicity and
    gender should enable NIH to target interventions more selectively and
    improve our ability to recruit and retain a diverse population of
    researchers.
                                     ______

                  Questions Submitted by Senator Arlen Specter

                           CURES ACCELERATION NETWORK

        Question. Moving the new authorized Cures Acceleration Network
    (CAN) forward is of critical importance. What would the timeline be for
    getting the program started if funding is provided?
        Answer. If funding is provided, the first step would be to appoint
    CAN's advisory board and identify priority areas. After this, the
    National Institutes of Health (NIH) would prepare grant and contract
    solicitation announcements within approximately 2 months of the first
    board meeting. Applicants would be given 60 days to prepare
    applications in response to the solicitation(s). The application
    reviews would occur within several weeks following receipt, and awards
    made rapidly thereafter. Under this timetable, we would expect to
    disburse awards within the first year.

                                CLINICAL CENTER

        Question. What is the current number of patients being treated at
    the Mark O. Hatfield Clinical Research Center in Bethesda? As the
    largest clinical research hospital in the world, what capacity is it?
    If it is not at full capacity when do you anticipate that it will be?
        Answer. As of May 26, 2010, the Mark O. Hatfield Clinical Research
    Center has seen 17,450 patients in the inpatient and outpatient
    settings; approximately 38,000 inpatient days and 61,000 outpatient
    visits this fiscal year. The current inpatient capacity at the Mark O.
    Hatfield Clinical Research Center is 234 beds. A new 6-bed high
    containment unit that will allow us to study patients with infectious
    diseases is scheduled to open shortly and will increase the Center's
    total capacity to 240 beds.
        In fiscal year 2010, the Mark O. Hatfield Clinical Research Center
    has been operating at an average daily census of 166 inpatients per day
    which represents an occupancy level of approximately 70 percent. Based
    on plans that the Institutes are making fiscal year 2011, we anticipate
    an increase in inpatient activity of approximately 2 percent more than
    fiscal year 2010. In addition, NIH leaders are exploring the
    feasibility of opening the Mark O. Hatfield Clinical Research Center to
    the outside research community, and discussions are underway with the
    NIH Scientific Management Review Board. Such a change could lead to
    increased utilization.

                               PANCREATIC CANCER

        Question. Pancreatic cancer research accounts for only about 2
    percent of NIH's budget, even though it is the forth leading cancer
    killer and has one of the lowest survival rates. What can be done to
    increase funding?
        Answer. Since the publication of Pancreatic Cancer: An Agenda for
    Action in 2001, the National Cancer Institute (NCI) has expanded its
    portfolio of pancreatic cancer research from $21.8 million in fiscal
    year 2001 to $89.7 million in fiscal year 2009, an increase of more
    than 300 percent. During this period, the total NCI budget increased by
    about 30 percent; thus, the growth in the pancreatic cancer portfolio
    has been approximately tenfold larger than the growth in the total NCI
    budget. As documented in Pancreatic Cancer: Six Years of Progress in
    2007, the NCI pancreatic cancer research portfolio has grown within
    each of the six major research priority areas identified in 2001.
        In addition to an increase in funding, there have also been
    increases in the number of projects funded (up more than 275 percent
    since fiscal year 2000), unique RO1 Grant Principal Investigators
    funded (up more than 200 percent since fiscal year 2000), and training/
    career development awards (up more than 65 percent since fiscal year
    2005). Part of the 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 addition, pancreatic cancer projects were also funded through
    the American Recovery and Reinvestment Act of 2009 (ARRA). In fiscal
    year 2009, 79 pancreatic cancer-related projects received ARRA funding
    totaling $10.7 million. These projects include some focused on
    training/career development that are relevant to growing the critical
    mass of pancreatic cancer investigators, a group of traditional RO1
    research grants, a Challenge Grant, and a Grand Opportunity or ``GO''
    grant. The NCI Community Cancer Centers Program, a group already
    working on pancreatic cancer, has been further developed with ARRA
    funds. The ACTNOW initiative, which supports high-priority, early-phase
    clinical trials of new cancer treatments on an accelerated timeline
    includes a clinical trial addressing pancreatic cancer. Finally, The
    Cancer Genome Atlas project (TCGA) is using ARRA funds to rapidly
    increase the number of cancers covered by the project, including
    pancreatic cancer. ARRA has provided a unique opportunity to accelerate
    progress in pancreatic cancer research.
        NCI has focused considerable expertise on assessing the state of
    the science in pancreatic cancer and developing a targeted network of
    pancreatic cancer experts for consultation with NCI program staff In
    2006, NCI created a Gastrointestinal Cancer Steering Committee (GISC)
    with seven specific disease-site task forces, including one focused on
    pancreatic cancer. GISC members include all Cooperative Group
    gastrointestinal disease committee chairs, representatives from the
    Specialized Programs of Research Excellence (SPOREs), Cancer Center and
    R01/P01 investigators, along with community oncologists,
    biostatisticians, patient advocates and NCI staff. Through GISC, NCI
    convened a Pancreas State of-the-Clinical Science meeting in 2007 to
    discuss the integration of basic and clinical knowledge into the design
    of clinical trials for pancreatic cancer and to define the direction
    for clinical trials investigation for pancreatic cancer over the next 3
    to 5 years. A Consensus Report from the meeting, published in the
    Journal of Clinical Oncology in November 2009, emphasized the
    importance of enhanced molecular targets and targeted drugs for
    pancreatic cancer, better preclinical models, and improved phase II
    studies. The GISC is an active part of NCI's programmatic development
    for pancreatic and other gastrointestinal cancers. The GISC' s
    pancreatic cancer task force provides important leadership, meeting on
    a monthly basis to coordinate strategy between the cooperative groups,
    identifying new leads to explore, and monitoring ongoing trials. Within
    the pancreatic cancer task force, a working group has been created to
    focus on development of trials for locally advanced disease. In
    addition, as part of the operational efficiency working group
    guidelines for the development of clinical trials, the pancreatic
    cancer task force is now operating under an accelerated timeline for
    the development of phase II and III clinical trials.
        Finally, in response to earlier congressional language, NCI will be
    holding an internal meeting this summer to discuss research and
    training initiatives relevant to pancreatic cancer.
        Question. In 2001, NCI developed a set of 39 recommendations for
    increasing pancreatic cancer research, including attracting more
    scientists to this field of study. Nine years later, only five of its
    own recommendations have been implemented. Over the same time period
    the NCI's budget has grown by more than $1 billion, so it's not a
    question of funds being available. Given the fact that pancreatic
    cancer deaths are increasing, what concrete steps will you take to make
    this field of study a higher priority?
        Answer. Since the publication of Pancreatic Cancer: An Agenda for
    Action in 2001, the NCI has expanded its portfolio of pancreatic cancer
    research from $21.8 million in fiscal year 2001 to $89.7 million in
    fiscal year 2009, an increase of more than 300 percent. During this
    period, the total NCI budget increased by about 30 percent; thus, the
    growth in the pancreatic cancer portfolio has been approximately
    tenfold larger than the growth in the total NCI budget. As documented
    in Pancreatic Cancer: Six Years of Progress in 2007, the NCI pancreatic
    cancer research portfolio has grown within each of the six major
    research priority areas identified in 2001.
        A genome-wide association study to uncover the causes of pancreatic
    cancer, known as PanScan, has identified five important genetic regions
    that greatly influence the risk of developing pancreatic cancer. NCI is
    now focused in detail on each of these genetic risk regions. NCI is
    active in the Pancreatic Cancer Genetic Epidemiology Consortium,
    founded to examine susceptibility genes in familial pancreatic cancer.
        Other initiatives include the Pancreatic Cancer Cohort Consortium,
    and pancreatic and GI SPOREs. In November 2009, NCI launched one of the
    largest phase III trials ever undertaken in pancreatic cancer (RTOG
    0848), intended to enroll 900 patients to evaluate both Erlotinib and
    chemoradiation as adjuvant treatment.
        Pancreatic cancer studies have been funded within the Cancer
    Nanotechnology Platform Partnerships, the Early Detection Research
    Network, and the Tumor Glycome Laboratories of the NIH Alliance of
    Glycobiologists for Detection of Cancer and Cancer Risk. NCI is
    collaborating with the Pancreatic Cancer Action Network (PanCAN) and
    the Lustgarten Foundation for Pancreatic Cancer research on the
    Pancreatic Cancer Research Map. This project facilitates collaborations
    among pancreatic cancer researchers to speed the development of
    national strategies, and leverage resources for pancreatic cancer
    research. The map provides a unified collection of pancreatic cancer
    research projects, funding opportunities, and investigators.
                                     ______

                  Questions Submitted by Senator Thad Cochran

                         SPINAL MUSCULAR ATROPHY (SMA)

        Question. What role can the National Institutes of Health (NIH)
    play in laying the groundwork for SMA and to develop new therapies and
    work with the Food and Drug Administration (FDA) to support new
    therapies? Please update the subcommittee on what are the next steps
    that NIH is planning to take to prepare for, support and sustain the
    efforts that will be necessary up to and through clinical trials for
    SMA?
        Answer. Due to NIH's continued investment in SMA research,
    including studies on disease mechanisms and preclinical/translational
    therapy development, the first treatments for SMA are now advancing
    through the therapeutic development pipeline. The NIH has taken a
    number of steps to continue to support development of potential
    treatments up to and through clinical trials.
        NIH supports a variety of projects for translating basic research
    findings into therapies that can be tested in a clinical setting. The
    SMA Project, funded by the NIH and guided by experts from industry,
    academia, NIH, and the FDA, is an innovative, contract-based,
    ``virtual-pharma'' program to develop drugs and test them in the
    laboratory. The project holds two patents on two sets of compounds that
    show significant promise and, assuming successful preclinical testing,
    a phase I clinical trial to assess safety should begin in 2011. The
    project is also continuing to pursue other leads.
        To complement the SMA project, the NIH also funds investigator-
    initiated therapy development projects. This year, National Institute
    of Neurological Disorders and Stroke (NINDS) began funding a major
    milestone-driven collaboration between an academic lab and a biotech
    company to develop a lead compound into a drug that is ready for
    clinical testing in SMA patients. An investigator-initiated grant
    funded by the National Institute of Child Health and Human Development
    is designed to assess the natural history of the disease and perform
    pilot studies to evaluate potential interventions in a broad cohort of
    SMA patients. Additionally, NIH has used American Recovery and
    Reinvestment Act (ARRA) funds to make investments in rapidly developing
    opportunities, including a Grand Opportunity grant on delivery of
    therapeutic genes for motor neuron diseases. Stem cell research
    relevant to SMA has also been funded, including studies of induced
    pluripotent stem cells derived from SMA patients.
        NIH has also made a commitment to support high-quality clinical
    trials for SMA and other pediatric disorders. In February, the NINDS
    Council approved NINDS-NET, a multi-site clinical research network to
    expedite early phase clinical trials of therapies from academic
    research, foundations, or biotech companies. Because all network
    participants are required to have expertise in clinical trials for
    pediatric neurological disorders as well as adult diseases, this
    clinical research network provides the framework for high-quality
    trials for SMA and other rare disorders.
        The NIH, working with SMA volunteer organizations, has organized a
    workshop for later this year that will focus on therapies that are
    approaching readiness for clinical testing, what hurdles remain, and
    what is needed for effective SMA clinical trials. A second workshop,
    organized by both the NIH and FDA, will address specifically the use of
    anti-sense oligonucleotides in treating neuromuscular disorders
    including SMA, and will provide FDA input into clinical and preclinical
    studies. Both of these workshops will not only facilitate communication
    among SMA researchers, NIH, and the FDA, but will also help the
    research community plan for moving therapies into clinical trials.

                                CROHN'S DISEASE

        Question. Dr. Collins, I want to thank you and the leadership of
    the National Institute of Diabetes and Digestive and Kidney Diseases
    for advancing research on Crohn's disease and ulcerative colitis. As
    you know, these are extremely painful and debilitating disorders that
    are increasing in prevalence. Can you tell us what needs to be done to
    translate the remarkable genetic discoveries of recent years into
    better treatments for patients?
        Answer. The NIH support for research on the genetics of Crohn's
    disease and ulcerative colitis--the two major forms of inflammatory
    bowel diseases (IBD)--is providing the foundation for the development
    of unique and effective therapies for patients who suffer from these
    diseases. Following the discovery of the first IBD-associated gene, the
    NIH established a major program in 2002--the IBD Genetics Consortium--
    to accelerate the discovery of genetic variants that are associated
    with the disease. To date, this very successful program has uncovered
    nearly 50 genetic variants that are associated with both major forms of
    IBD. Progress in this area was bolstered by recent investments from
    ARRA, which provided additional support for the consortium to enhance
    its ability to expand and develop resources. In addition, ARRA
    supported innovative projects to identify genetic variations that are
    less common amongst people with Crohn's disease and extend the success
    of genome wide association studies to identify genetic variations that
    predispose individuals from different ethnic groups to developing IBD.
    As researchers continue to discover additional genetic variants
    associated with IBD, it will be important for these advances to be
    translated into better treatments for patients. Through ARRA and
    regular appropriations, the NIH is supporting research to define the
    biological processes that are perturbed by genetic variants associated
    with IBD. In some cases, genetic variants that have limited direct
    associations with IBD may have significant biological consequences, and
    it will be important to consider these factors when developing models
    of disease risk. By further understanding the genetic variants
    associated with disease and their molecular consequences, researchers
    will be able to develop and validate biomarkers as indicators of
    disease risk, disease prognosis, and patient responses to therapies. In
    addition, as the biological pathways underlying IBD are better defined,
    researchers will identify targets for developing new therapeutics to
    help treat these painful and debilitating disorders.

                                MINORITY HEALTH

        Question. How will the new data collection requirements on race and
    ethnicity, primary language, geographic location, and disability status
    affect research at NIH? How will this information be used? Are you
    collaborating with the existing Department of Health and Human
    Services, Office of Minority Health (OMH) in order to coordinate and
    establish an effective Government effort to address minority health
    issues?
        Answer. The new data collection requirements will advance NIH's
    research-based efforts for improving the health of the Nation. The
    limited specificity, uniformity and quality of data collection and
    reporting procedures has been a significant restraint in identifying
    and monitoring efforts to reduce health disparities. According to a
    recent report by the Institute of Medicine (IOM) ``Race, Ethnicity, and
    Language Data: Standardization for Health Care Quality Improvement,
    ``from the Subcommittee on Standardized Collection of Race/Ethnicity
    Data for Healthcare Quality Improvement,'' consistent methods for
    collecting and reporting healthcare data on racial and ethnic
    minorities are essential to informing evidence-based disparity
    reduction initiatives.
        In addition, as the demographics of the United States continue to
    shift, it is essential to understand the diversity of the Nation based
    on race, ethnicity, primary language, and disability status. Collecting
    information on the geographic distributions of racial and ethnic
    populations will aid researchers in understanding how geographic
    location and environmental factors for example, contribute to the
    existence and persistence of health disparities. During the past 10
    years there has been a growing appreciation of the role these factors
    play in health disparities. Collecting this data will assist
    researchers in understanding how these factors, working independently
    and dependently, contribute to the excess burden of disease, morbidity,
    and mortality experienced by racial and ethnic minorities relative to
    majority populations.
        This enhanced data collection will be useful in clinical research,
    especially in Comparative Effectiveness Research, where there will be
    the need to collect information on these racial and ethnic subgroups to
    produce statistically reliable evidence-based results. Statistical
    oversampling of certain subpopulations in clinical comparative
    effectiveness research will be done as needed. In addition to improving
    data collection across Federal categories of race and ethnicity,
    information is needed on racial and ethnic subgroups. This new data
    collection will be critical to monitoring the health status and needs
    of immigrant and language minority populations. This calculates to
    approximately 100 different ethnic groups with populations more than
    100,000 living in the United States.
        Health disparities are persistent and eliminating them requires an
    in-depth understanding of how multiple factors--social and biological--
    act independently and dependently. Collecting information on race,
    ethnicity, primary language, disability status, and geographic location
    will allow researchers to better understand these factors and their
    interactions. Scientists will use it to design interventions tailored
    to meet the needs of racial and ethnic populations as a function of
    primary language or geographic location, or other factors.
        The NIH, through the National Center on Minority Health and Health
    Disparities (NCMHD), has had a long-standing tradition of collaboration
    and coordination of minority health and health disparities activities
    with the HHS OMH. Over the years the NCMHD and OMH have worked
    collaboratively to address a number of minority health issues both
    domestically and internationally, as well as support several minority
    health initiatives with funding from some of the Institutes and
    Centers. Most recently, the NIH has participated in:
      --The development of the HHS National Partnership Action Plan led by
            OMH;
      --NIH is represented on the HHS Health Disparities Council which
            deals with minority health and health disparities issues across
            the HHS and for some time has been led by the OMH;
      --NCMHD and OMH are collaborating on an ARRA initiative to develop
            Centers of Excellence for Comparative Effectiveness Research
            through the NCMHD Centers of Excellence; and
      --NCMHD and OMH serve as two of three Federal Government co-leads for
            the Federal Collaboration on Health Disparities Research
            (FCHDR) which is aimed at enhancing wide Federal Government
            coordination around minority health and health disparities.

                     INSTITUTIONAL DEVELOPMENT AWARD (IDEA)

        Question. Does the list of eligible States ever change to reflect
    their greater or lesser success over time in attracting competitive NIH
    research funding?
        Answer. When Congress authorized the Institutional Development
    Award (IDeA) program in 1993, its intent was to promote geographic
    distribution of NIH funding across the United States. in order to
    increase the research capacity in eligible States. The eligibility to
    participate in the IDeA program has been evaluated on a yearly basis
    and the list of eligible States has not changed over the years with the
    exception of Alabama, which was once an IDeA eligible State that became
    ineligible based on its success in obtaining NIH funding. The current
    list of IDeA eligible States can be found on the National Center for
    Research Resources' (NCRR) Web site at http://www.ncrr.nih.gov/
    research_infrastructure/institutional _development_award/.
        The current IDeA eligibility criteria are based on two components:
    (1) a success rate for competing research projects and centers of less
    than 20 percent for obtaining NIH grant awards during 2001-2005; or (2)
    less than $120 million average NIH funding during 2001-2005 (regardless
    of success rate), excluding IDeA awards and R&D contracts.
        NCRR is currently evaluating whether the IDeA eligibility criteria
    are still appropriate to accomplish the legislative intent. As it does
    so, the eligibility criteria and the IDeA-eligible States will remain
    the same.
                                     ______

                Questions Submitted by Senator Richard C. Shelby

                                   BIODEFENSE

        Question. In National Institute of Allergy and Infectious Diseases
    (NIAID)'s Strategic Plan for Biodefense Research 2007 Update, NIAID
    outlined three ``broad spectrum'' strategies as a way to maximize
    biodefense capabilities. One of these strategies was the exploration of
    broad spectrum platforms, which NIAID describes as standardized methods
    that can be used to significantly reduce the time and cost required to
    bring medical countermeasures to market. Please explain how much
    funding has been spent in this area and what milestones have been
    reached.
        Answer. NIAID's product development strategy has broadened from a
    ``one bug-one drug'' approach toward a more flexible, broad-spectrum
    approach. This process involves developing medical countermeasures that
    are effective against a variety of pathogens and toxins, developing
    technologies that can be widely applied to improve classes of products,
    and establishing platforms that can reduce the time and cost of
    creating new products. The broad-spectrum strategy recognizes both the
    expanding range of biological threats and the limited resources
    available to address each individual threat. NIAID provided $653
    million in fiscal year 2009 to a number of initiatives that have the
    potential to lead to the development of broad spectrum platforms.
    Examples of milestones in the development of broad-spectrum strategies
    that have been facilitated by NIAID funding include:
      --The preclinical development of AdvaxTM, a vaccine
            adjuvant platform technology. AdvaxTM has been
            approved for human use in Australia for at least five different
            candidate vaccines and currently is being tested in seasonal
            and pandemic influenza vaccines and hepatitis B vaccines that
            are ready to enter phase III clinical trials.
      --The development of LJ001, a broad-spectrum antiviral that has shown
            activity against multiple viruses, including influenza, Ebola,
            Marburg, hepatitis C, and West Nile.
      --Syntiron's broad-spectrum vaccine technology that is currently used
            for candidate vaccines for Staphylococcus, Salmonella, plague,
            and anthrax.

                                   BIODEFENSE

        Question. Specifically, equine source plasma has been successfully
    used in the development of passive antibody therapy for postexposure
    treatment of agents such as botulinum toxin. I understand this same
    technique can be used for treatment of a number of the Category A
    biological threat agents such as Bacillus anthracis, hemorrhagic fevers
    (i.e., Ebola and Marburg), and Yersinia pestis. Is NIAID familiar with
    this platform of therapeutics and its successes? Has NIAID applied
    funding either from within its directly appropriated funds or from
    BARDA transferred funds to the development of passive antibody
    therapeutics? If so how much and on what projects?
        Answer. NIAID is significantly involved in the development and use
    of passive antibody therapy for postexposure treatment of agents such
    as botulinum toxin and has provided more than $92 million in funding
    over the past 3 years for the development of passive antibody therapy
    for Category A agents. Among other efforts, NIAID supported the
    development of the botulinum toxoid antibody from horses for a product
    that is now included in the Strategic National Stockpile; coordinated
    with the Biomedical Advanced Research and Development Authority (BARDA)
    for development of animal models in support of licensure of botulinum
    anti-toxins; and supported initial work to develop ricin polyclonal
    antibodies from equine antisera.

                             CONCLUSION OF HEARINGS

        Senator Harkin. The subcommittee will stand recessed.
        [Whereupon, at 11:05 a.m., Wednesday, May 5, 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 2011

                                  ----------

                                           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 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
    by the United States Senate's Subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies.
        AACI applauds recent budgetary commitments--notably, increased
    funding for the National Institutes of Health (NIH) and support from
    the Obama administration through the American Recovery and Reinvestment
    Act of 2009 (ARRA)--that have created a more encouraging landscape for
    cancer research compared to recent years. We hope that this support
    will continue in the years ahead, to ensure that this recognition of
    the importance of biomedical research is sustained.
        AACI congratulates the administration and Congress on their
    commitment to ensuring quality care for cancer patients, as well as for
    providing researchers with the tools that they need to develop better
    cancer treatments and, ultimately, to cure this disease.
        President Obama has released his fiscal year 2011 budget which
    includes a $1 billion increase to NIH budget for an expansion of
    support for biomedical research. This funding boost would make the NIH
    budget $32.1 billion, representing a 3.2 percent increase. The National
    Cancer Institute (NCI) would receive an additional $161 million, or
    3.16 percent more, for a total of $5.26 billion.
        AACI has joined its colleagues in the biomedical research community
    in supporting the proposed increase for NIH and in calling on Congress
    to further strengthen the impact of the President's request by
    increasing funding to $35 billion.
        With the extra NIH and NCI funding, the cancer community will be
    better equipped to leverage ARRA financial support. ARRA dollars have
    helped to sustain the momentum achieved in reducing death rates from
    cancer, and they are proving to be an effective means of stimulating
    local economies and creating or maintaining jobs throughout the
    country.
        For example, The Ohio State University Comprehensive Cancer Center
    and the Winthrop P. Rockefeller Cancer Institute at the University of
    Arkansas for Medical Sciences are moving forward with major
    construction projects supported by ARRA funding. Another AACI member,
    the University of New Mexico Cancer Center, is buying equipment and
    hiring more staff with ARRA money, while a researcher at Tennessee's
    Vanderbilt-Ingram Cancer Center is studying imaging techniques in
    colorectal cancer with help from ARRA grants (Association of American
    Cancer Institutes, AACI Update, February 2010).
        Maintaining the flow of sufficient, dependable funding streams for
    NCI will help to continue the work that started under the stimulus
    plan. It will also serve as recognition that $70 million worth of great
    ideas--the approximate amount of ARRA funding for NCI to date--might
    not have been explored if it were not for the administration's
    unprecedented infusion of funds for cancer research. And much untapped
    scientific potential remains.
    Cancer Research: Benefiting all Americans
        Cancer's financial and personal impact on America is substantial
    and growing--1 in 2 men and 1 in 3 women will face cancer in their
    lifetimes, and cancer cost our Nation more than $228 billion in 2008
    (Centers for Disease Control and Preventions, Addressing The Cancer
    Burden: At A Glance 2010). This year, cancer will become the world's
    number one killer. Investing in cancer research is a prudent step--both
    for the health of our Nation and for our Nation's economic well-being.
        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.
        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.
        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.
    Clinical Trials
        Clinical trials are the cornerstone of cancer research, and it is
    commonly held that ``yesterday's clinical trials are today's standard
    therapies''. Without clinical trials we cannot discover new cancer
    drugs and better treatments, and without volunteers we cannot conduct
    trials.
        With no more than 5 percent of adult cancer patients participating
    in clinical trials, attracting volunteers to trials has been a long-
    standing struggle for cancer researchers. And yet, thanks in large part
    to advances realized through clinical trials, two-thirds of cancer
    patients now survive at least 5 years after diagnosis, compared with
    only half a generation ago.
        Unfortunately, running a clinical trial from start to finish can be
    prohibitively complicated and expensive. While the Nation's cancer
    centers represented by AACI work to untangle red tape and other factors
    that can derail trials, a serious obstacle stands largely beyond their
    control--the cost to patients of participating in trials.
        Section 2709 of the Patient Protection and Affordable Care Act of
    2010 requires health insurance plans, including those offered through
    the Federal Employee Health Benefit Program, to provide coverage for
    routine costs associated with participation in clinical trials.
        Commercial health insurers often refuse to pay for routine care
    costs associated with a clinical trial, arguing that the trial is
    ``investigational'' and thus optional or unnecessary. Consequently,
    patients experience financial difficulties that limit their
    participation in trials. That, in turn, has a negative impact on
    research and patients' ability to receive promising treatments that are
    available through trials. It slows the development of new cancer
    therapies.
        Routine costs associated with clinical trials include physician
    visits, blood work, hospital stays and x-rays. These costs would
    usually be reimbursed by the insurer if the patient was not
    participating in a clinical trial. The investigational portion of the
    trial (usually a new drug or device) is not charged to the patient or
    the insurer.
        Since 1994, 27 States and the District of Columbia have passed laws
    requiring insurance coverage for routine patient care costs when
    patients participate in clinical trials, and another 5 States have
    established cooperative agreements with insurers to do so. However,
    beyond the patchwork nature of such coverage, some of these laws do not
    necessarily require insurers to cover all cancer patients, such as
    those in phase I or II clinical trials, or those with employer self-
    insured plans, in which a large company self-insures its employees.
    With the new Federal policy, all cancer patients can now afford to
    enroll in a potentially life-saving clinical trial.
    The Nation's Cancer Centers
        The nexus of cancer research in the United States is the Nation's
    network of cancer centers 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 $3.15
    billion from NCI to conduct cancer research; this represents 65 percent
    of NCI's total budget (U.S. Department of Health and Human Services,
    National Institutes of Health, National Cancer Institute 2008 Fact
    Book). In fact, 84 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.
        Collaboration between the cancer centers' and NCI is also
    essential, and extramural input in shaping NCI's programmatic
    priorities is vital for effecting cancer research breakthroughs.
    Furthermore, AACI endorses the call for greater collaboration expressed
    in recent testimony by Robert S. DiPaola, MD, Director of the Cancer
    Institute of New Jersey, delivered before the Health Subcommittee of
    the House Energy and Commerce Committee. The association is in strong
    agreement with Dr. DiPaola that ``culture of collaboration'' needs to
    be nurtured among NCI-designated cancer centers, as well as between
    such centers and the pharmaceutical and biotechnology companies that
    develop drug treatment for cancer and related illnesses.
        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 depends 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.
    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 (American Society of Clinical Oncology, 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,
    2007).
        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. (American Cancer Society, Cancer Facts and Figures 2008).
        Cancer physicians--while essential--are only one part of the
    oncology workforce that is in danger of being stretched to the breaking
    point. For example, the Health Resources and Services Administration
    has predicted that by 2020, more than 1 million nursing positions will
    go unfilled. 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 where demand for oncology services far outstrips the system's
    ability to provide adequate care for all.
    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 places the highest priority on affording all Americans
    access to superior cancer 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 testimony highlighting funding priorities for nursing
    education and research programs in fiscal year 2011. AACN represents
    nearly 650 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
    Advanced Practice Registered Nurses (APRNs), nurse faculty, and
    researchers.
    The Nationwide Nursing Shortage
        The United States is in the midst of a nursing shortage that has
    impacted the quality care in our Nation's healthcare system for 12
    years. 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 due to factors such as an
    aging population, increased complexity of care, and a significant
    population with chronic diseases. Moreover, the new healthcare reform
    law will increase access to care, which will require a surge in the
    number healthcare providers. RNs and APRNs will be in high demand. This
    comes at a time when the U.S. Bureau of Labor Statistics (BLS),
    currently reports that nursing is the Nation's top profession in terms
    of projected job growth with more than 581,000 new positions being
    created through 2018 (a 22 percent increase in the workforce). 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 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 capacity barriers in schools of nursing. According to
    AACN, 54,991 qualified applicants were turned away from baccalaureate
    and graduate nursing programs in 2009 primarily due to insufficient
    number of faculty, clinical sites, classroom space, clinical
    preceptors, and budget constraints. Federal support for nursing
    education is critical at this juncture in American history. National
    reform goals cannot be met without an adequate number of nurses to
    provide the cost-effective and quality care associated with the nursing
    discipline.
    Nursing Workforce Development Programs: A Proven Solution
        For nearly five decades, the title VIII Nursing Workforce
    Development Programs (42 U.S.C. 296 et seq.) 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. AACN's 2009-2010 title VIII Student Recipient
    Survey included responses from 1,420 students who noted that these
    programs played a critical role in funding their nursing education,
    which will ultimately help them to achieve future career goals. The
    students responding to the title VIII survey have career aspirations
    that meet the direct needs of the healthcare system and the profession.
    A high percentage of the students surveyed (48.9 percent) reported that
    their career goal is to become a nurse practitioner. Given the demand
    for primary care providers, the title VIII funds are helping to support
    the next generation of these essential practitioners. Moreover, the
    nurse faculty shortage continues to inhibit the ability of nursing
    schools to increase student capacity and address the shortage. Of the
    students who responded to the survey, 40.6 percent stated their
    ultimate career goal was to become nurse faculty. Providing support for
    title VIII is the key to help schools expand student capacity, fill
    vacant nursing positions, and, in turn, improve healthcare quality.
        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. The student
    recipients reported that more funding was needed for these programs to
    help offset the considerable cost of nursing education. Fifty-two
    percent of the students responded that the title VIII funding paid for
    25 percent or less of their total student loans. Of those students, 26
    percent stated that the funding paid for less than 5 percent of their
    total nursing student loans.
        Over the last 45 years, Congress has used the title VIII
    authorities as a mechanism to address past nursing shortages. When the
    need for nurses was great, higher funding levels were appropriated. For
    example, during the nursing shortage in the 1970s, Congress provided
    $160.61 million to the title VIII programs in 1973. Adjusting for
    inflation to address the 37-year difference, $160.61 million (fiscal
    year 1973 funding level) in 2010 dollars would be approximately $784
    million. At a time when nursing economists project the current shortage
    to be twice as large as any nursing shortage experienced in this
    country since the mid-1960s, more must be invested in title VIII to
    decrease the magnitude of the RN demand.
        AACN respectfully requests $267.3 million (a 10 percent increase)
    for the Nursing Workforce Development programs authorized under title
    VIII of the Public Health Service in fiscal year 2011. Last year, your
    subcommittee provided a significant funding boost for title VIII that
    helped support the Loan Repayment and Scholarship program and Nurse
    Faculty Loan program. These increases will help bolster the pipeline of
    nurses and nurse faculty, which are so critical to reversing the
    nursing shortage. It is extremely important to maintain last year's
    funding level for these crucial programs in fiscal year 2011. AACN
    believes the 10 percent requested increase should be directed to the
    four title VIII programs that have not kept pace with inflation since
    fiscal year 2005. These programs include the Advanced Education
    Nursing, Nursing Workforce Diversity, Nurse Education, Practice, and
    Retention, and Comprehensive Geriatric Education programs, which help
    expand nursing school capacity and increase patient access to care. The
    10 percent increase awarded to these programs in proportion to their
    fiscal year 2010 funding level would be a wise investment of Federal
    resources.
    Nursing Research: Supporting Health Promotion and Disease Prevention
        The National Institute of Nursing Research (NINR) is 1 of the 27
    Institutes and Centers at the National Institutes of Health (NIH). As
    the nucleus for nursing science, NINR funds research that establishes
    the scientific basis for health promotion, disease prevention, and
    high-quality nursing care services to individuals, families, and
    populations. 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.--Presently, 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 that
            promotes prevention is a major focus of the new health reform
            law, and NINR is a leader in funding scientific research to
            discover optimal prevention methods.
      --Eliminating Health Disparities.--Race, gender, socioeconomic
            status, ethnic origin, geography, and culture impact the
            healthcare of individuals and communities. NINR is committed to
            funding research that investigates culturally appropriate
            interventions and care strategies focused on at-risk
            populations.
      --Improving Quality of Life.--Disease prevention is a critical goal
            of clinical research. NINR is committed to funding research
            that assists individuals with managing their own health
            conditions, decreases adverse symptoms, and reduces the burden
            on caregivers.
      --Setting Directions for End-of-Life Research.--Palliative care and
            respect for those at the end of their life is a critical part
            of treatment for serious and life-threatening illness. This
            care is provided alongside disease treatment to ease suffering
            and improve the quality-of-life for the patient. NINR seeks,
            through scientific research, to improve the understanding of
            the processes underlying palliative care efforts and develop
            effective strategies to optimize care across all patient
            populations.
        Research conducted at NINR improves quality of care to benefit
    health both globally and nationally. With increased appropriations for
    NINR, more comprehensive, complex, and longitudinal studies could be
    funded in the areas provided below as well as meet the current goals,
    projects, and priorities of the Institute.
      --Expand the scope of science in symptom management;
      --Global health;
      --Increase funding for scientist-initiated research applications;
      --Expand the translation, dissemination, and outreach of NINR
            generated research to bridge the gap between scientific
            evidence and clinical practice;
      --Evaluate the impact of nursing science on the health of the Nation;
            and
      --Support future nurse researchers.
        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.
        NINR's fiscal year 2010 funding level of $145.66 million is
    approximately 0.47 percent of the overall $31.247 billion NIH budget
    (see Figure 1). 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, NINR must receive additional funding. Cuts in
    funding have impeded NINR from supporting larger comprehensive studies
    needed to advance nursing science and improve the quality of patient
    care.

        Therefore, AACN respectfully requests $160 million for the National
    Institute of Nursing Research, an additional $14.34 million over the
    fiscal year 2010 level.
    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 (2010), 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 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 2011.
    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. The National
    Institute of Nursing Research 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 $267.3 million for title VIII programs, $160
    million for NINR, and $50 million for the Capacity for Nursing Students
    and Faculty Program in fiscal year 2011. 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 pleased to submit this testimony in support of
    increased funding in fiscal year 2011 for programs at the Health
    Resources Services Administration (HRSA), 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 26 colleges of osteopathic medicine and three branch
    campuses that offer the doctor of osteopathic medicine degree. Today,
    more than 18,000 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 HRSA,
    support the training and education of health practitioners to enhance
    the supply, diversity, and distribution of the healthcare workforce,
    acting as an essential part of the healthcare safety net and 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,
    the anticipated demand for access to care once 32 million more
    Americans have health insurance as a result of healthcare reform will
    strain an already fragile healthcare system. While AACOM appreciates
    the investments that this subcommittee has made in these programs, it
    recommends increasing funding to $330 million in fiscal year 2011 for
    the title VII programs. Investment in these programs, including the
    Training in Primary Care Medicine Program, the Health Careers
    Opportunity Program, and the Centers of Excellence, is necessary to
    address the primary care workforce shortage. Strengthening the
    workforce has been recognized as a national priority, and the
    investment in these programs recommended by AACOM will help sustain the
    health workforce expansion supported by the American Recovery and
    Reinvestment Act (ARRA) and necessitated by the demand for a well
    trained, diverse workforce that this country will experience as a
    result of healthcare reform.
    National Health Service Corps (NHSC)
        AACOM applauds Congress for increasing the authorization to $414
    million in fiscal year 2011 for the NHSC through direct appropriations
    and including the authorized Community Health Center Fund (CHC Fund),
    which also covers the NHSC, in the Patient Protection and Affordable
    Care Act. Approximately 50 million Americans live in communities with a
    shortage of health professionals, lacking adequate access to primary
    care. Through scholarships and loan repayment, NHSC supports the
    recruitment and retention of primary care clinicians to practice in
    underserved communities. At a field strength of 4,760 in fiscal year
    2009, the NHSC still fell more than 24,000 practitioners short of
    fulfilling the need for primary care, dental, and mental health
    practitioners in federally designated Health Professions Shortage Areas
    (HPSAs), as estimated by HRSA. Growth in HRSA's Community Health Center
    Program must be complemented with increases in the recruitment and
    retention of primary care clinicians to ensure adequate staffing, which
    the NHSC provides. ARRA funding for the NHSC has been vital in this
    regard, and additional investment will be necessary to sustain the
    progress as the ARRA funding period ends. AACOM supports the
    President's budget request of $169 million for the NHSC program in
    fiscal year 2011, which would be sufficient to trigger the release of
    dollars from the CHC Fund. AACOM further recommends that the
    subcommittee include report language directing the Secretary to provide
    enhanced funding for the NHSC, as required under the Patient Protection
    and Affordable Care Act.
    Medical School Development
        The President's fiscal year 2011 budget request included $100
    million for the development of new medical schools in HPSAs. The grant
    program would be administered by HRSA. The budget projected that these
    funds would support approximately 20 grants for new academic health
    centers to provide training and research in community-oriented
    settings. The goal is to increase clinical training in HPSAs as well as
    to increase the number of new providers who go on to practice in these
    underserved areas. AACOM supports the appropriation of these funds at a
    time when it is critical to support the training of new medical
    students in order to ensure that Americans have access to care.
    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. To maintain a robust research agenda,
    further investment will be needed. AACOM recommends $35 billion in
    fiscal year 2011 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 to continue
    fulfilling this essential research role.
    AHRQ
        The 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 Patient Centered Health Research
    Program in recent years, as well as the funding provided to AHRQ in the
    ARRA, will help AHRQ generate more of this 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, especially research in patient safety and
    prevention and care management research. AACOM recommends $611 million
    in fiscal year 2011 for AHRQ, as requested by the President. 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

        AACP and its member colleges and schools of pharmacy appreciate the
    continued support of the U.S. Senate Appropriations Subcommittee on
    Labor, Health and Human Services, and Education, and Related Agencies.
    Our Nation's 116 accredited colleges and schools of pharmacy are
    engaged in a wide-range of programs supported by grants and funding
    administered through the U.S. Department of Education and agencies of
    the Department of Health and Human Services (HHS). 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.

    U.S. 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 $5,710.
      --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 $126 million.
        AACP recommends a funding level of $160 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.

      U.S. 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 $611 million
    for AHRQ programs in fiscal year 2011.
        Pharmacy facultyare strong partners with the Agency for Healthcare
    Research and Quality (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.
        Researchers, including faculty at the University of Illinois,
    Chicago School of Pharmacy, supported through an AHRQ DEcIDE Network
    contract determined that a specific drug triad regularly prescribed to
    patients suffering from chronic obstructive pulmonary disease reduced
    the risk of death. Researchers determined that other drug combinations
    increased the risk of death. This research was published in the
    Archives of Internal Medicine allowing for ready translation of this
    life-saving knowledge into practice. AHRQ Contract Number 290-05-0038
        Pharmacy faculty researchers at the University of Iowa, supported
    by AHRQ grant HS018353-01, will seek to improve the quality of
    medication therapy management programs (MTM) which is a mandated
    service of the Medicare Part D benefit. This research will provide
    additional guidance to CMS, PDPs, and other payers and organizations
    interested in improving the quality of care provided to patients in
    regard to their medications.
    Centers for Disease Control and Prevention (CDC)
        AACP supports the CDC Coalition recommendation of $8.8 billion for
    CDC core programs in fiscal year 2011.
        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.
        Researchers at the University of Mississippi School of Pharmacy
    will be supported in their work to develop and test new malaria drugs
    by CDC grant 3U01CI000211-05S1.
    Health Resources and Services Administration (HRSA)
        AACP supports the Friends of HRSA recommendation of $8.5 billion
    for fiscal year 2011.
        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
        AACP recommends a program funding of $5 million for fiscal year
    2011 for the Office of Pharmacy Affairs.
        AACP member institutions are actively engaged in Office of Pharmacy
    Affairs (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 federal 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. The PPC provides services free-of-charge to the public and
    health professionals 24 hours-a-day, 365 days-a-year. A recent USC
    study found that for every $1 spent on the Palmetto Poison Center, more
    than $7 were 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 $600 million for title VII and VIII
    programs in fiscal year 2011.
        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, University of
    Montana). This program 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 necessary for the Institute of
    Medicine's recommendations of improving quality through team-based,
    patient-centered care.
                                     ______

       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 continuing
    investment in research through the American Recovery and Reinvestment
    Act of 2009 (ARRA) and the fiscal year 2010 budget will support current
    projects and provide for new efforts in the fight against cancer. These
    new efforts are now underway and 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 uncover the discoveries today that will lead to
    more lives saved 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 is occurring 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 strongly
    support biomedical research funding at the National Institutes of
    Health (NIH), including carrying out President Obama's vision for
    doubling cancer research funding in order to find a cure for cancer in
    our time. Therefore, the AACR supports the biomedical community's
    recommendation of sustaining the current funding for NIH, which would
    amount to $35.2 billion in fiscal year 2011.
    AACR: Fostering a Century of Research Progress
        AACR has been moving cancer research forward since its founding in
    1907. Celebrating its 101st annual meeting in Washington, DC, this
    April, the AACR and its more than 30,000 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 last century, 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 rare 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 2010. 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 is
    essential to avoid this cancer crisis.
    Blueprint for Progress: National Cancer Institute (NCI) Strategic
            Objectives
        Basic, translational, and clinical cancer research in this country
    are conducted primarily through three venues--government, academia, and
    the nonprofit sector--and the pharmaceutical/biotechnology industry.
    The Congress provides the appropriations for 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 2011'' 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 $1.2 billion as proposed for
    fiscal year 2011, the NCI will have the capability to rebuild America's
    research infrastructure capacity and accelerate research progress in
    critical priority areas:
      --understanding the causes and mechanisms of cancer;
      --accelerating progress in cancer prevention;
      --improving early detection and diagnosis;
      --developing effective and efficient treatments;
      --understanding the factors that influence cancer outcomes;
      --improving the quality of cancer care;
      --improving the quality of life for cancer patients, survivors, and
            their families; and overcoming cancer health disparities.
    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. In more than half
    the States, grants and contracts to institutions exceed $15 million.
    This Federal investment also provides needed economic stimulus to local
    economies. For example, on average, each $1 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 2010
    appropriations and the ARRA funding 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 sustaining the current investment in the NCI with a budget of
    $5.8 billion.
    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.
    Accelerating Progress in Cancer Prevention
        Preventing cancer is far more cost-effective and desirable than
    treating it. NCI's strategic plan supports research in: understanding
    and modifying behaviors that increase risk; reducing the influence of
    genetic and environmental risk factors; and interrupting the initiation
    of cancer through early medical intervention. A critical component of
    this multifaceted approach is ensuring that evidence-based advances
    that have been shown to inform and motivate people toward healthy
    behaviors are widely disseminated and accessible.
        The NCI uses multidisciplinary teams and a systems biology approach
    to identify early events and determine how to modify them. More than
    half of all cancers are related to modifiable behavioral factors,
    including tobacco use, diet, physical inactivity, sun exposure, and
    failure to get cancer screenings. The NCI supports research to
    understand how people perceive risk, make health-related decisions, and
    maintain healthy behavior. Prevention is the keystone to success in the
    battle against cancer.
    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's 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 and breakthroughs resulting
    from The Cancer Genome Atlas project are leading the way toward an era
    of personalized medicine.
    Overcoming Cancer Health Disparities
        Some minority and underserved population groups suffer
    disproportionately from cancer. Solving this issue will contribute
    significantly to reducing the cancer burden. The NCI's investments in
    this area include: studying the factors that cause cancer health
    disparities; working with underserved communities to develop targeted
    interventions; developing the knowledge base for integrating cancer
    services to the underserved; collaborating to implement culturally
    appropriate information dissemination approaches to underserved
    populations; and examining the role of health policy in eliminating
    cancer health disparities. One size does not fit all in cancer research
    special populations require special treatment to achieve success.
    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 support 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 the AACR Chemistry in Cancer Research
            Working Group;
      --convening and supporting the AACR-FDA-NCI Cancer Biomarkers
            Collaborative;
      --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; and
      --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 $228 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 1 percent reduction in
    mortality from cancer would be worth nearly $500 billion in social
    value. In addition, investments in cancer research stimulate the local
    economy today and promise 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, AACR urges the
    United States House of Representatives to support a budget of $35.2
    billion for the NIH, including $5.8 billion for NCI.
                                     ______

       Prepared Statement of the American Association for Dental Research

    Introduction
        Mr. Chairman and members of the subcommittee, I am David Wong,
    Director of the Dental Research Institute at the University of
    California, Los Angeles (UCLA) School of Dentistry. My testimony is on
    behalf of the American Association for Dental Research (AADR).
        I thank the subcommittee for this opportunity to testify about the
    exciting advances in oral health science. Research funded by the
    National Institutes of Health (NIH) has returned significant dividends
    in terms of 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). Since 1948, NIDCR has
    conducted research, trained researchers, and disseminated health
    information in order to improve the health of Americans and make it
    possible for them to live longer and healthier lives.
    What Is the American Association for Dental Research?
        The AADR, headquartered in Alexandria, Virginia, is a nonprofit
    organization with more than 4,000 individual members and 100
    institutional members within the United States. Its mission is: (1) to
    advance research and increase knowledge for the improvement of oral
    health; (2) to support and represent the oral health research
    community; and (3) to facilitate the communication and application of
    research findings. AADR is the largest Division of the International
    Association for Dental Research.

    Why Oral Health Is Important
        Oral health is an essential component of health throughout life.
    Poor oral health and untreated oral diseases and conditions can have a
    significant impact on quality of life. They can affect the most
    significant human needs including the ability to eat and drink,
    swallow, maintain proper nutrition, smile, and communicate.
        Over the past 50 years, there has been a dramatic improvement in
    oral health. Still, oral diseases remain a major concern. Oral health
    and general health are inseparable. Diseases and conditions of the
    mouth have a direct impact on the health of the entire body.
        Good oral health can help improve birth outcomes, keep children
    from developing painful cavities and prevent seniors, and those with
    chronic health conditions, from developing life-threatening
    complications. In recent years, new scientific reports have linked poor
    oral health to poor general health. Dental decay (cavities) is one of
    the most common chronic illnesses among children. Although most dental
    diseases are preventable, many children unnecessarily suffer from
    dental disease because of inadequate home care and lack of access to
    dental services. An estimated 51 million school hours per year are lost
    in the United States because of dental-related illness. Poor oral
    health has been related to decreased school performance, poor social
    relationships, and less success later in life.
        Employed adults in the United States lose more than 164 million
    hours of work each year as a result of oral health problems or dental
    visits. About 30 percent of adults 65 years old and older have lost all
    of their natural teeth. Older Americans with the poorest oral health
    are those who are economically disadvantaged, lack insurance, and are
    members of racial and ethnic minorities.
        As the Nation ages, oral health issues related to gum disease and
    the impact of medical treatments and medicines will increase.
    Maintaining good oral health throughout a person's life is important.

    Research Accomplishments
        Oral and Systemic Health.--The oral cavity plays an important role
    in the overall health of the body. Some say the mouth is the body's
    mirror. And while associations between oral and systemic health can be
    made, specific cause-and-effect relationships remain elusive. It has
    been reported that 3 out of every 4 Americans have signs of mild
    periodontal disease. Almost 30 percent show signs of the more severe
    disease, chronic periodontitis. We now have reason to believe that the
    health of your teeth and gums may have a significant effect on the
    overall health of your body. Recent scientific literature suggests a
    strong relationship between oral disease and other systemic diseases
    and medical conditions.
        According to numerous studies, there are three ways oral disease
    may affect your overall health. First, bacteria from your gums enter
    the saliva. From the saliva it may adhere to water droplets within the
    air you inhale each time you breathe. These bacteria laden water
    droplets may be aspirated into the lungs, potentially causing pulmonary
    infection and pneumonia. This can be a serious problem for the elderly
    or those who may suffer from generalized weakened immunity, associated
    with chronic obstructive pulmonary disease (COPD). Inflammatory
    mediators found in inflamed gums called ``cytokines'' can also enter
    your saliva.
        Secondly, bacteria associated with periodontal disease can enter
    the body's circulatory system through the gums (periodontium) around
    teeth and travel to all parts of the body. As the oral bacteria
    travels, it may cause secondary infections or it may contribute to the
    disease process in other tissues and organ systems.
        Finally, inflammation associated with periodontal disease may
    stimulate a second systemic inflammatory response within the body and
    contribute to or complicate other disease entities that may have an
    inflammatory origin such as, cardiovascular disease, diabetes, and
    kidney disease.
        The goal of many studies being conducted at dental schools and
    research centers throughout the world is to understand just how oral
    bacteria affect overall health. As these studies are published,
    healthcare professionals will begin to better understand the underlying
    biological mechanisms that are responsible for this oral systemic
    connection.
        Health Disparities.--Despite remarkable improvements in the oral
    health of many, not everyone in the nation has benefited equally. Oral,
    dental, and craniofacial conditions remain among the most common health
    problems for low-income, racial/ethnic minority, disadvantaged,
    disabled, and institutionalized individuals across the life span.
    Dental caries, periodontal diseases, and oral and pharyngeal cancer are
    of particular concern.
        The NIDCR Health Disparities Research Program supports studies
    that:
      --Provide a better understanding of the basis of health disparities
            and inequalities;
      --Develop and test interventions tailored and targeted to underserved
            populations; and
      --Explore approaches to the dissemination and implementation of
            effective findings to assure rapid translation into practice,
            policy and action in communities.
        The NIDCR supports:
      --Research that seeks to understand a broadened array of determinants
            of disparities/inequalities in oral health status and care at
            multiple levels;
      --Interventional research designed to have a meaningful impact on
            oral health status and quality of life that will influence
            action in healthcare, public policy, or diseases/disability
            prevention in communities;
      --Cost analyses of interventions as well as comparative effectiveness
            studies;
      --Behavioral and social science intervention research that is
            grounded in theory and considers mechanisms of action;
      --Research that utilizes new technologies and approaches that are
            practical, culturally appropriate and sustainable for
            individuals, caregivers, and workers.
      --Novel interventions as well as those that have previously been
            untested with vulnerable populations.
        Researchers from many backgrounds and disciplines contribute to
    health disparities/inequalities research. Some of the disciplines of
    researchers on health disparities/inequalities research teams are
    genetics, dentistry and dental hygiene, and medicine and nursing. Teams
    that conceptualize, plan and conduct this type of research include
    community members of the disadvantaged and vulnerable population
    subgroups as partners in the research enterprise.
        Salivary Diagnostics.--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 years of research, saliva is poised to be used as a noninvasive
    diagnostic fluid for a number of oral and systemic conditions. Salivary
    diagnostics has come of age. In just a little more than 6 years,
    research supported by the NIDCR has sprung to the forefront of basic,
    translational, and clinical research.
        Saliva not only combats bacteria and viruses that enter the mouth,
    but it also 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 altered in the presence of a disease. Saliva is very easy to
    collect, providing a major advantage over the use of blood or urine for
    diagnostic tests. Saliva has the same biomarkers found in blood and
    urine.
        Oral cancer affects 38,000 Americans each year. The death rate
    associated with this cancer is especially high due to delayed
    diagnosis. Saliva is not only more accurate than blood for oral cancer
    detection, but saliva diagnostics will likely outperform other biomedia
    for other disease diagnostics as well. The risk of oral cancer,
    prostate cancer, breast cancer, and a host of other health conditions
    can be determined and often prevented when acting on information
    provided from a saliva hormonal assay. Saliva tests could prove to be a
    potentially life-saving alternative to detect diseases where early
    diagnosis is critical, such as certain cancers. For most cancers,
    successful treatment depends on early detection and successful
    prevention depends on the accurate evaluation of risk. Early detection
    of oral cancer will increase survival rate, improve the quality of life
    of cancer patients, and will result in a significant reduction in
    healthcare costs.
    Conclusion
        As you can see, Mr. Chairman, 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 NIDCR in
    particular, is essential for continued improvement in the oral health
    of Americans.
        In order to sustain momentum in the field of oral and systemic
    health, health disparities, and salivary diagnostics, it is requested
    that NIH receive a fiscal year 2011 appropriation of $35 billion, of
    which NIDCR should receive an fiscal year 2011 appropriation of $481
    million.
        Thank you for the opportunity to testify.
                                     ______

        Prepared Statement of the American Academy of Family Physicians

        As one of the largest national medical organizations, representing
    94,700 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 continue its
    commitment to title VII in fiscal year 2011 and increase funding for
    other key Health Resources and Services Administration programs to
    allow health reform to succeed. We also recommend increased funding for
    the Agency for Healthcare Research and Quality to provide better
    healthcare all.

                  HEALTH RESOURSES AND SERVICES ADMINISTRATION

        The Patient Protection and Affordable Care Act (Public Law 111-148)
    holds the promise of health security for Americans and moves us toward
    genuine health system reform, but it will require the support of this
    subcommittee to invest in the necessary primary care physician
    workforce. Primary care physicians will serve as a strong foundation
    for a more efficient and effective healthcare system. We are pleased
    that the health reform law reauthorizes the title VII health
    professions programs including the grants for the education and
    training of primary care physicians under title VII, section 747.
    Workforce Shortages
        Successful implementation of health reform requires an investment
    to strengthen our Nation's primary care workforce. The current national
    primary care physician workforce of just more than 200,000 is estimated
    to be 8,000-10,000 lower than projected demand based on adjusted
    average population utilization patterns, according to the Robert Graham
    Center for Policy Studies in Family Medicine and Primary Care. However,
    distribution is not equitable leaving many areas with physician
    shortages, especially in rural and underserved communities with
    measurable social deprivation.
        In the coming years, medical services utilization is likely to rise
    given the increasing and aging population as well as the insured status
    of more of the populace. Those demographic trends will cause primary
    care physician shortages to worsen. By 2025, the current downturn in
    primary care physician production is expected to yield a workforce 28.5
    percent below need based on current practice models or 50 percent below
    the level needed to provide all Americans with a patient-centered
    medical home.
        The recently enacted health reform legislation includes a number of
    provisions to increase the primary care workforce. It amends and
    expands many of the existing health workforce programs authorized under
    title VII (health professions) and makes a number of changes to
    Medicare graduate medical education (GME) payments to teaching
    hospitals, in part to encourage the training of more primary care
    physicians. The new law also establishes a national commission to study
    projected health workforce needs and make appropriate recommendations.
    Increasing the level of Federal funding for primary care training would
    reinvigorate medical education, residency programs, as well as academic
    and faculty development in primary care to prepare physicians to
    support the patient centered medical home.
        This subcommittee has demonstrated its commitment to a strong
    primary care workforce by doubling the appropriation for training under
    title VII section 747 of the Public Health Services Act in the American
    Recovery and Reinvestment Act of 2009 (Public Law 111-5).
        The AAFP urges the subcommittee to provide a fiscal year 2011
    appropriation of $170 million for the title VII section 747 Primary
    Care Training and Enhancement and the Integrative Academic
    Administrative Units programs as authorized by the Patient Protection
    and Affordable Care Act. We also recommend an appropriation of at least
    $600 million for all of the Health Professions Training Programs
    authorized under title VII of the Public Health Services Act.
    Rural Health Needs
        Physician shortages are harder for Americans in rural areas who
    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.
        We were pleased that title VII, section 749B, the ``Rural Physician
    Training Grants'' program, was enacted to help medical schools to
    recruit students most likely to practice medicine in underserved rural
    communities, provide rural-focused training and experience, and
    increase the number of recent medical school graduates who practice in
    underserved rural communities.
        Family physicians provide the majority of care for America's
    underserved and rural populations.\1\ 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.
    ---------------------------------------------------------------------------
        \1\ 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.
        The AAFP requests that the Committee provide $4 million in fiscal
    year 2011 for title VII section 749B Rural Physician Training Grants.
    The AAFP also encourages the subcommittee to provide $176 million for
    the programs administered by HRSA's Office of Rural Health to address
    the many unique health service needs of rural communities.
    Teaching Health Centers
        The AAFP supported the authorization in the health reform
    legislation of the innovative Teaching Health Centers program under
    title VII section 749A to increase primary care physician training
    capacity. Federal financing of graduate medical education has led to
    training which occurs mainly in hospital inpatient settings in spite of
    the fact that most patient care is delivered outside of hospitals in
    ambulatory settings across the Nation. As a result, we have been
    training physicians using experiences which poorly prepare them to
    practice primary care in the community outside the hospital.
        The Teaching Health Center program will train primary care
    residents in nonhospital settings where most primary care is delivered.
    A Teaching Health Center can be any community based ambulatory care
    setting that operates a primary care residency program including
    Federally Qualified Health Centers or Federally Qualified Health
    Centers Look Alikes, Rural Health Clinics, Community Mental Health
    Centers, a Health Center operated by the Indian Health Service, or a
    center receiving title X grants.
        We were pleased that the Patient Protection and Affordable Care Act
    authorized a mandatory appropriations trust fund of $230 million over 5
    years to fund the operations of Teaching Health Centers. However, if
    this program is to be effective, there must be funds for the planning
    grants to establish newly accredited or expanded primary care residency
    programs.
        The AAFP recommends that the subcommittee appropriate the full
    authorized amount for the new title VII Teaching Health Centers
    development grants of $50 million for fiscal year 2011.
    National Health Service Corps
        The National Health Services Corps (NHSC) has long served to
    provide access to healthcare to underserved Americans and offer
    incentives for practitioners to enter primary care. NHSC also provides
    important student debt relief for new physicians.
        Student debt was found to be a significant barrier to the
    production of primary care physicians by a report published in March
    2009, by the Graham Center with the support of the Macy Foundation.\2\
    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. We recognize that this subcommittee provided an increase
    for the NHSC in the American Recovery and Reinvestment Act, and we
    commend Congress for increasing the authorization level for the NHSC in
    the new health reform law.
    ---------------------------------------------------------------------------
        \2\ The Robert Graham Center. Specialty and Geographic Distribution
    of the Physician Workforce: What Influences Medical Student & Resident
    Choices? March 2, 2009.
    ---------------------------------------------------------------------------
        The AAFP recommends that the National Health Service Corps receive
    $414.1 million in fiscal year 2011 as authorized in the Patient
    Protection and Affordable Care Act which makes $290 million of that
    amount available from a fund created in section 10503.
    Workforce Commission
        The AAFP has called for a commission on national health workforce
    issues which represents the multiple stakeholders and reports to
    Congress and the Executive Branch as appropriate. We were pleased that
    the health reform bill established a National Health Care Workforce
    Commission to provide ``analysis of, and recommendations for,
    eliminating the barriers to entering and staying in primary care,
    including provider compensation.'' We also recognize the importance of
    the National Center for Health Care Workforce Analysis as well as State
    and Regional Centers for such analysis. The legislation authorized such
    sums as necessary to establish the Commission as well as $8 million in
    planning grants and $150 million for implementation grants. The
    National Center was authorized at $7.5 million annually and the State
    and Regional Centers were authorized at $4.5 million annually.
        The AAFP recommends that the subcommittee fully fund the National
    Health Care Workforce Commission, the National and State and Regional
    Centers for Health Care Workforce Analysis in fiscal year 2011.

                   AGENCY FOR HEATLHCARE RESEARCH AND QUALITY

        To assure the success of health reform, we must also focus on
    paying for quality rather than quantity. The mission of the Agency for
    Healthcare Research and Quality (AHRQ)--to improve the quality, safety,
    efficiency, and effectiveness of healthcare for all Americans--closely
    mirrors the 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 patient-centered, comparative
    effectiveness research.
    Primary Care Extension Program
        The AAFP commends the Congress for authorizing in the Patient
    Protection and Affordable Care Act a Primary Care Extension Program to
    be administered by AHRQ to provide support and assistance to primary
    care providers about evidence-based therapies and techniques so that
    providers can incorporate them into their practice. Family physicians
    Kevin Grumbach, MD and James W. Mold, MD, MPH recognized that small
    primary care practices need a similar kind of support offered by the
    Federal Government to farms by the Cooperative Extension Service to
    implement innovation and best practices.\3\
    ---------------------------------------------------------------------------
        \3\ Grumbach K, Mold JW. A Health Care Cooperative Extension
    Services: Transforming Primary Care and Community Health. JAMA, June
    24, 2009--Vol. 301, No. 24.
    ---------------------------------------------------------------------------
        The AAFP requests that the subcommittee provide $731 million for
    AHRQ in fiscal year 2011 to provide for the funding requested by the
    President's budget request of $611 million as well as the important new
    Primary Care Extension program authorized by the health reform law at
    $120 million.
                                     ______

    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 2011 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
        The aging of the baby boomer generation will result in an increase
    in the proportion of persons older than 65 from 12.7 percent currently
    to 20 percent in 2030, with the fastest growing segment of the
    population consisting of age 85 and older. During the same period, the
    number of older adults with major psychiatric illnesses will more than
    double, from an estimated 7 million to 15 million individuals, meeting
    or exceeding the number of consumers in discrete, younger age groups.
        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 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. AAGP
    is deeply grateful to this subcommittee and its House counterpart for
    providing, in the appropriations bill for fiscal year 2010, funding for
    a follow-up study of the current and projected mental and behavioral
    healthcare needs of the American people, particularly for aging and
    growing ethnic populations. This study, first proposed by Senator Kohl
    in the Retooling the Health Care Workforce for an Aging America Act (S.
    245), will complement the 2008 IOM study in providing in-depth
    consideration of the mental health needs of geriatric and ethnic
    minority populations that were precluded by the broad scope of the
    earlier one.
        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.
        Already, there are programs administered by the Bureau of Health
    Professions in the HHS Health Resources and Services Administration
    administers that are aimed to help to assure adequate numbers of
    healthcare practitioners for the Nation's geriatric population,
    especially in underserved areas. The breadth of these programs has been
    strengthened by provisions from S. 245 included in the recently enacted
    Patient Protection and Affordable Care Act (PPACA).
        The geriatric health professions program supports these important
    initiatives:
      --The Geriatric Education Center (GEC) program provides
            interdisciplinary training for healthcare professionals in
            assessment, chronic disease syndromes, care planning, emergency
            preparedness, and cultural competence unique to older
            Americans. PPACA authorizes $10.8 million in supplemental
            grants for the GEC Program to support training in geriatrics,
            chronic care management, and long-term care for faculty in a
            broad array of health professions schools, as well as direct
            care workers and family caregivers. GECs receiving these grants
            are required to develop and include material on depression and
            other mental disorders common among older adults, medication
            safety issues for older adults, and management of the
            psychological and behavioral aspects of dementia in all
            appropriate training courses.
      --The Geriatric Training for Physicians, Dentists, and Behavioral and
            Mental Health Professionals 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 geriatric specialists in junior faculty
            positions who are committed to teaching geriatrics in
            professional schools. PPACA expands the disciplines eligible
            for the awards. GACA recipients are required to provide
            training in clinical geriatrics, including the training of
            interdisciplinary teams of healthcare professionals.
      --PPACA authorized a new Geriatric Career Incentive Awards Program in
            title VIII of the Public Health Service Act for grants to
            foster great interest among a variety of health professionals
            in entering the field of geriatrics, long-term care, and
            chronic care management. This program was authorized for $10
            million over 3 years.
      --A new program, authorized by PPACA at $10 million for 3 years, will
            provide advanced training opportunities for direct care workers
            in the field of geriatrics, long-term care or chronic care
            management.
        AAGP strongly supports increased funding for the existing programs,
    particularly as the disciplines included have been expanded, and
    funding to fully authorized levels for the new programs.
    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,
    $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.
        AAGP believes that it is critical that NIH begin to invest
    increased funding in future evidence-based treatments for our Nation's
    elders. 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.

                Study on NIH Funding for Mental Disorders among Older
                        Adults
        As little emphasis has been placed on the development of new
    treatments for geriatric mental disorders, AAGP encourages 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 Accountablity Office (GAO) study
    on spending by NIH on conditions and illnesses related to the mental
    health of older individuals. 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
        It is critical that there be adequate funding for the mental health
    initiatives under the jurisdiction of the Center for Mental Health
    Services (CMHS) within the Substance Abuse and Mental Health Services
    Administration (SAMHSA). While research is of critical importance to a
    better future, today's patients must also receive appropriate treatment
    for their mental health problems.

                Evidence-based Mental Health Outreach and Treatment for the
                        Elderly
        For the last 8 years $5 million has been allocated for evidence-
    based mental health outreach and treatment to the elderly. AAGP urges
    an increase in funding from $5 million to $10 million for this
    essential program to disseminate and implement evidence-based practices
    in routine clinical settings across the States.

                Centers of Excellence for Depressive and Bipolar Disorders
        PPACA also included authorization for a new national network of
    centers of excellence for depressive and bipolar disorders, which will
    enhance the coordination and integration of physical, mental and social
    care that are critical to the identification and treatment of
    depression and other mental disorders across the lifespan. The work of
    these centers will help to disseminate and implement evidence-based
    practices in clinical settings throughout the country. AAGP strongly
    supports funding for the centers authorized by this legislation.
    Conclusion
        AAGP recommends:
      --Increased funding for the geriatric health professions education
            programs under title VII of the Public Health Service Act and
            full funding for new programs authorized by the PPACA;
      --Funding to support clinical trials involving older adults;
      --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;
      --Funding for Centers of Excellence for Depressive and Bipolar
            Disorders.
                                     ______

        Prepared Statement of the American Association of Immunologists

        The American Association of Immunologists (AAI), a not-for-profit
    professional association representing more than 6,500 of the world's
    leading experts on the immune system, appreciates having this
    opportunity to submit testimony regarding fiscal year 2011
    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.\1\ With more than 80 percent of the $30.5 billion budget
    awarded to scientists in communities throughout the United States and
    around the world, NIH funding advances not only immunological and
    biomedical research, but also regional and national economies by
    creating and supporting skilled jobs that are focused on improving
    human health.\2\
    ---------------------------------------------------------------------------
        \1\ AAI members receive grants from the National Institute of
    Allergy and Infectious Diseases (NIAID), the National Cancer Institute;
    the National Institute on Aging, and the National Institute of
    Arthritis and Musculoskeletal and Skin Diseases, but may also receive
    grants from other NIH Institutes and 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.''
    See http://www.nih.gov/about/budget.htm (2/8/10).
    ---------------------------------------------------------------------------
    The Immune System's Wide Reach
        Influenza, HIV/AIDS, malaria, tuberculosis, salmonella, the common
    cold, and more--all are infectious diseases that challenge and
    sometimes overcome the defenses mounted by the immune system. Chronic
    diseases like cancer, diabetes, multiple sclerosis, rheumatoid
    arthritis, asthma, inflammatory bowel disease, and lupus, are either
    caused by--or due in large part to--an overactive or underactive immune
    response.\3\ Scientists' discovery of ways to prevent, diagnose, and
    treat these diseases depends on increased knowledge in the field of
    immunology.\4\ Important new challenges require understanding the
    immune response to: (1) pathogens that threaten to become the next
    pandemic,\5\ (2) man-made and natural infectious organisms that are
    potential agents of bioterrorism (including plague, smallpox, and
    anthrax),\6\ and (3) environmental threats. The immune system,
    therefore, plays a crucial role in preserving human and animal health
    \7\ and increasingly--in our fast-paced, interconnected world--ensuring
    both community and global health.
    ---------------------------------------------------------------------------
        \3\ The immune system works by recognizing and attacking 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 destroying the virus,
    bacterium, or tumor cell--or partially, resulting in a less serious
    illness. It is also responsible for the rejection response following
    transplantation of organs or bone marrow. The immune system can also
    malfunction, causing the body to attack itself, resulting in an
    ``autoimmune'' disease, such as Type 1 diabetes, multiple sclerosis,
    lupus or rheumatoid arthritis.
        \4\ Although the first vaccine (against smallpox) was developed in
    1798, most of our basic understanding of the immune system has
    developed in the last 30-40 years, making immunology ripe for new
    discoveries.
        \5\ While researchers and public health professionals must respond
    to emergent threats, 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, and
    seeking optimized flu vaccines and delivery methods.
        \6\ 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.
        \7\ Research on the immune system leads to new vaccines/treatments
    for pets and livestock, and improves our understanding of animal to
    human transmission [as, for example, with H1N1 influenza (``swine
    flu'')].
    ---------------------------------------------------------------------------
    Recent Advances in Immunological Research
        Knowledge of the intricacies of the immune system has led to
    unprecedented medical advances such as successful organ
    transplantation, new vaccines, and better treatments. Recent
    immunological advances may further yield profound improvements for
    people afflicted with debilitating diseases. One such advance involves
    lupus, a serious chronic autoimmune disease affecting some 1.5 million
    Americans.\8\ Exciting recent results from the largest clinical trials
    yet performed have opened the door for the first new drug for effective
    lupus treatment in 50 years. These trials show that a new type of
    therapeutic that inactivates the natural molecule ``BLyS'' results in
    substantial disease reduction in lupus patients. Both the discovery of
    BLyS and the development of novel effective treatments are a product of
    decades of basic immunology research by scientists supported by NIH and
    other nonprofit organizations.
    ---------------------------------------------------------------------------
        \8\ See http://www.lupusresearch.org/about/press-room/press-
    releases/new-study-findings-represent.html.
    ---------------------------------------------------------------------------
        An advance with international importance was the successful
    response of the biomedical research community to the 2009 swine flu/
    H1N1 influenza outbreak. Researchers working against time were able to
    develop an effective vaccine within 4 months after the first U.S. case
    was diagnosed on April 13, 2009 \9\. This success depended on years of
    comprehensive basic research on the immune and viral systems, including
    the ability to identify the molecular DNA sequence of the virus
    necessary to produce a vaccine. This provided an excellent ``test run''
    for a future pandemic of even more significant public health
    concern,\10\ and demonstrated a successful collaboration among basic
    and translational scientists, clinical practitioners, and
    pharmacological companies against an infectious disease pandemic.
    ---------------------------------------------------------------------------
        \9\ See http://www3.niaid.nih.gov/about/directors/pdf/
    110409NIAIDStatementLHHSH1N1.pdf. On 7/22/09, NIAID reported the launch
    of clinical trials on two candidate H1N1 vaccines in adults (see http:/
    /www.nih.gov/news/health/jul2009/niaid-22.htm). On 8/18, NIAID
    announced it would begin trials in children (see http://
    www3.niaid.nih.gov/news/newsreleases/2009/H1N1pedvax.htm). The Food and
    Drug Administration approved a vaccine on 9/15; it was made publicly
    available on 10/5 (see http://www3.niaid.nih.gov/about/directors/pdf/
    110409NIAIDStatementLHHSH1N1.pdf).
        \10\ A pandemic can be mild or serious. Seasonal influenza, which
    may or may not lead to a pandemic, results in 200,000 hospitalizations
    and 36,000 deaths nationwide in an average year. A serious influenza
    pandemic could result in the hospitalization of nearly 10 million
    Americans and the death of almost 2 million, at a projected cost of
    over $680 billion. (See ``Pandemic Influenza: Warning, Children At-
    Risk,'' Trust for America's Health, 10/07, at http://
    healthyamericans.org/reports/fluchildren/KidsPandemicFlu.pdf).
    ---------------------------------------------------------------------------
        Another advance involves the successful use of new and improved
    technologies to identify all the human genes stimulated by a vaccine,
    in this case, the Yellow Fever vaccine.\11\ This was the first time
    scientists could determine how different individuals immunized with the
    same vaccine responded on a molecular level; this approach will
    significantly enhance our ability to determine how effective vaccines
    stimulate protective responses and may lead the way to customize
    vaccines to be more effective for the individual.
    ---------------------------------------------------------------------------
        \11\ Published in Nature Immunology, Jan. 10, 2009, pp. 116-25,
    from the laboratory of B. Pulendran.
    ---------------------------------------------------------------------------
    The NIH Budget: Building on a Strong Start
        AAI greatly appreciates the strong support of this subcommittee for
    medical research, from doubling the NIH budget (fiscal year 1999 to
    fiscal year 2003), to passing the fiscal year 2009 and 2010
    Appropriations Acts, to including in the ``American Recovery and
    Reinvestment Act of 2009'' (ARRA) a $10.4 billion supplemental
    appropriation for NIH. ARRA underscored both the President's and
    Congress's realization that investing in biomedical research would not
    only improve individual and global health, but also stimulate economic
    activity and job creation: NIH has estimated that each NIH grant
    supports, on average, ``6 to 7 in-part or full scientific jobs,'' \12\
    while Families USA, a nonprofit consumer organization, has found that,
    on average, each $1 of NIH funding going into a State generates more
    than twice as much in State economic output.\13\
    ---------------------------------------------------------------------------
        \12\ Testimony of Raynard S. Kington, M.D, Ph.D., Acting Director,
    National Institutes of Health, Witness appearing before the House
    Subcommittee on Labor-HHS-Education Appropriations, March 26, 2009.
        \13\ ``In Your Own Backyard: How NIH Funding Helps Your State's
    Economy,'' Families USA (June 2008).
    ---------------------------------------------------------------------------
        As a result of this generous infusion of funds, NIH has also been
    able to fund many excellent, innovative projects with great promise for
    advancing human health, and to invest in modernizing the Nation's
    research infrastructure. And while AAI--and the biomedical research
    community--are deeply grateful for these funds, AAI is concerned that
    imminent advances may not come to fruition if the fiscal year 2011
    appropriations level fails to acknowledge the crucial role that ARRA
    funding now plays within the NIH budget. The AAI funding recommendation
    for fiscal year 2011 is premised on that concern and designed to
    address that future.
    AAI Recommendation for NIH Funding for Fiscal Year 2011: Achieving the
            President's Vision
        Although President Obama's proposed fiscal year 2011 budget of
    $32.2 billion, a 3.2 percent increase over the regular fiscal year 2010
    appropriations level, is a good next step toward achieving the
    President's vision that ``investments in research will improve and save
    countless lives for generations to come . . .,'' \14\ it will not
    ensure that important ongoing research currently funded by combined
    regular and supplemental (ARRA) appropriations is not interrupted,
    suspended or delayed. AAI urges the subcommittee to provide NIH with a
    fiscal year 2011 budget of $37 billion to preserve ongoing research and
    to enable NIH to grow modestly from its 2009 and 2010 program levels of
    $35 billion.\15\ Such a budget would also provide NIH with
    predictable, sustained funding that stabilizes ongoing research
    projects and the overall research enterprise, inspiring many of our
    brightest young students to pursue careers in biomedical research.\16\
    ---------------------------------------------------------------------------
        \14\ See http://www.whitehouse.gov/blog/09/09/30/
    An_Historic_Commitment_to_Research.
        \15\ After adding an increase for the projected rate of biomedical
    research inflation (3.2 percent), and (2) a modest increase for growth
    (2.5 percent), the total increase requested above the fiscal year 2010
    program level is 5.71 percent.
        \16\ Presidential candidate Barack Obama acknowledged that
    ``Sustained and predictable increases in research funding will allow
    the United States to . . . provide greater support for . . . young
    scientists at the beginning of their careers.'' (See http://
    www.sciencedebate2008.com/www/index.php?id=42) (8/30/08).
    ---------------------------------------------------------------------------
    NIH Research Priorities for Fiscal Year 2011
        AAI is concerned that the President's proposed budget focuses
    primarily on large-scale, trans-NIH initiatives, at the expense of
    investigator-initiated research, a proven route to medical advancement.
    In fact, the fiscal year 2011 budget decreases the number of competing
    Research Project Grants by 199. AAI urges that the budget support the
    NIH Director's stated commitment to individual investigator-initiated
    research. In addition, AAI supports the proposed 6 percent increase for
    the Ruth Kirschstein National Research Service Awards, a long-needed
    training stipend increase for the young scientists who are the next
    generation of research leaders. AAI also supports the President's
    request for $300 million for the Global Fund to Fight AIDS,
    Tuberculosis, and Malaria--infectious diseases which devastate people
    and communities worldwide.
    Preserving High-quality Peer Review
        Peer review is at the heart of the many decades of successful
    biomedical research in the United States; the NIH peer review system is
    internationally respected and highly successful. NIH is currently
    implementing dramatic changes intended to improve its system. Although
    AAI supports NIH's effort to address legitimate problems, AAI is
    concerned that some of the changes have harmed the peer review system,
    its reviewers, and its applicants, and believes that independent
    oversight and evaluation is urgently needed.
    The NIH Common Fund
        AAI is concerned that the proposed increase of $17.5 million for
    the NIH Common Fund (CF), which supports trans-NIH initiatives, may
    over-emphasize large-scale, multi-disciplinary initiatives, as compared
    with entrepreneurial investigator-initiated approaches. Although AAI
    recognizes the value of interdisciplinary research, the CF should not
    permit the funding less well regarded 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 so that individual researchers, who drive American
    scientific advancement, are not marginalized.
    NIH Operations and Oversight
        AAI strongly supports the President's request for $1.525 billion
    for the NIH Research, Management, and Services account, which supports
    the management, monitoring, and oversight of all research activities.
    NIH must have adequate resources to supervise and oversee its
    increasingly large and complex portfolio.
    The NIH Public Access Policy
        AAI requests that the subcommittee require NIH to publicly report
    on the cost of the NIH Public Access Policy (Policy), including the
    cost of implementing the voluntary Policy (May 2, 2005-January 11,
    2008); the mandatory Policy (fiscal year 2009 and fiscal year 2010);
    and the Policy in fiscal year 2011 (projected cost). AAI believes that
    the Policy duplicates publications and services which are already
    provided cost-effectively and well by the private sector. The private
    sector, including not-for-profit scientific societies, already
    publishes--and makes publicly available--thousands of scientific
    journals (and millions of articles) that report cutting-edge research
    funded by NIH and other entities. AAI urges that, rather than
    supporting a Government bureaucracy that competes with private
    publishers, NIH should partner with publishers to enhance public access
    while addressing publishers' key concerns, including respecting
    copyright law and ensuring journals' continued ability to provide
    quality, independent peer review of NIH-funded research.
    Conclusion
        AAI thanks the subcommittee for its strong support for biomedical
    research, the NIH, and the biomedical researchers who devote their
    lives to scientific discovery and the prevention, treatment, and cure
    of disease.
                                     ______

       Prepared Statement of the Association of American Medical Colleges

        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association representing all 131 accredited U.S. medical
    schools; nearly 400 major teaching hospitals and health systems; and
    nearly 90 academic and scientific societies. Through these institutions
    and organizations, the AAMC represents 128,000 faculty members, 75,000
    medical students, and 110,000 resident physicians. The association
    appreciates the opportunity to address four programs that play critical
    roles in assisting medical schools and teaching hospitals to fulfill
    their missions of education, research, and patient care: the National
    Institutes of Health (NIH); the Agency for Healthcare Research and
    Quality (AHRQ); health professions education funding through the Health
    Resources and Services Administration (HRSA)'s Bureau of Health
    Professions; and the National Health Service Corps (NHSC). The AAMC
    thanks the Subcommittee for its steadfast support of these programs.
        National Institutes of Health (NIH).--The AAMC believes that the
    NIH is one of the Nation's greatest achievements. The Federal
    Government's unwavering support for medical research through the NIH
    has created a scientific enterprise that is the envy of the world and
    has contributed greatly to improving the health and well-being of all
    Americans--indeed of all humankind.
        The AAMC supports the Obama administration's proposal to increase
    funding for NIH to $32 billion in fiscal year 2011. Boosting NIH's
    funding to a level that keeps pace with biomedical inflation recognizes
    the need for continued, predictable growth in the Nation's medical
    research effort. At a time when the Nation faces extraordinary fiscal
    challenges, the President's commitment to medical research is a wise
    investment that will yield long-term benefits for our Nation's health.
    The partnership between NIH and America's medical schools and teaching
    hospitals continues to serve as the engine for this Nation's search for
    an ever-greater understanding of the mechanisms underlying human health
    and disease. The foundation of scientific knowledge that continues to
    be built through NIH-funded research drives medical innovation that
    improves health and quality of life through new and better diagnostics,
    improved prevention strategies, and more effective treatments.
        For example, a new ability to comprehend the genetic mechanisms
    responsible for disease is already providing insights into diagnostics
    and identifying a new array of drug targets. We are entering an era of
    personalized medicine, where prevention, diagnosis, and treatment of
    disease can be individualized, instead of using the standardized
    approach that all too often wastes healthcare resources and potentially
    subjects patients to unnecessary and ineffective medical treatments and
    diagnostic procedures.
        Peer-reviewed, investigator-initiated basic research is the heart
    of NIH research. These inquiries into the fundamental cellular,
    molecular, and genetic events of life are essential if we are to make
    real progress toward understanding and conquering disease. Additional
    funding is needed to sustain and enhance basic research activities,
    including increasing support for current researchers and promoting
    opportunities for new investigators and in those areas of biomedical
    science that have historically been underfunded.
        The application of the results of basic research to the detection,
    diagnosis, treatment, and prevention of disease is the ultimate goal of
    medical research. Clinical research not only is the pathway for
    applying basic research findings, but it often provides important
    insights and leads to further basic research opportunities. The AAMC
    supports additional funding for the continued expansion of clinical
    research and clinical research training opportunities, including
    rigorous, targeted postdoctoral training; developmental support for new
    and junior investigators; and career support for established clinical
    investigators, especially to enable them to mentor new investigators.
        Anecdotal evidence suggests that changes in healthcare delivery
    systems and other financial factors pose a serious threat to the
    research infrastructure of America's medical schools and teaching
    hospitals, particularly for clinical research. The AAMC supports
    efforts to enhance the research infrastructure, including resources for
    clinical and translational research; instrumentation and emerging
    technologies; and animal and other research models.
        The AAMC supports efforts to reinvigorate research training,
    including developing expanded medical research opportunities for
    minority and disadvantaged students. For example, the volume of data
    being generated by genomics research, as well as the increasing power
    and sophistication of computing assets on the researcher's lab bench,
    have created an urgent need, both in academic and industrial settings,
    for talented individuals well-trained in biology, computational
    technologies, bioinformatics, and mathematics to realize the promise
    offered by modern interdisciplinary research.
        The AAMC is heartened by the administration's proposals to provide
    a 6 percent stipend increase for predoctoral and postdoctoral research
    trainees supported by NIH's Ruth L. Kirschstein National Research
    Service Awards program. These stipend increases are necessary if
    medical research is to remain an attractive career option for the
    brightest U.S. students. Attracting the most talented students and
    postdoctoral fellows is essential if the United States is to retain its
    position of world leadership in biomedical and behavioral research.
        As President Obama noted in his State of the Union address, ``We
    need to encourage American innovation.'' Research conducted and
    supported by NIH has played a major role in the development of the
    biotechnology, pharmaceutical, and medical device industries and
    continues to provide the basis for their continued success. Sustaining
    this Nation's investment in medical research will continue to
    strengthen our Nation's economic health by creating skilled and high-
    paying jobs, new products and industries, and improved technologies.
        Agency for Healthcare Research and Quality.--Complementing the
    medical research supported by NIH, AHRQ sponsors health services
    research designed to improve the quality of healthcare, decrease
    healthcare costs, and provide access to essential healthcare services
    by translating research into measurable improvements in the healthcare
    system. The AAMC firmly believes in the value of health services
    research as the Nation continues to strive to provide high-quality,
    efficient, and cost-effective healthcare to all of its citizens. The
    AAMC supports the President's request for AHRQ, which calls for $611
    million for the agency in fiscal year 2011.
        As the lead Federal agency to improve healthcare quality, AHRQ's
    overall mission is to support research and disseminate information that
    improves the delivery of healthcare by identifying evidence-based
    medical practices and procedures. The funding increase proposed in the
    President's budget will allow AHRQ to continue to support patient-
    centered health research and other valuable research initiatives,
    including strategies for translating the knowledge gained from patient-
    centered research into clinical practice, healthcare delivery, and
    provider and patient behaviors. These research findings will better
    guide and enhance consumer and clinical decisionmaking, provide
    improved healthcare services, and promote efficiency in the
    organization of public and private systems of healthcare delivery.
        While we support a strong investment in patient-centered health
    research, we also encourage the subcommittee to maintain balance across
    AHRQ's portfolio to allow the agency to support the full spectrum of
    activities aligned with its mission. For example, the President's
    budget does not continue funding for the Centers for Education and
    Research in Therapeutics (CERTs) grants, and instead, funds six new
    CERTs in the Patient-Centered Health Research portfolio and one new
    pediatric patient safety CERT. The AAMC believes AHRQ is perfectly
    positioned to take the lead on improving the quality of healthcare
    through the reduction of medical errors, and strongly supports the
    CERTs program; we encourage the subcommittee not to limit or narrow its
    scope. The request also decreases other initiatives within the agency's
    ``Crosscutting Activities'' portfolio, including a proposed decrease
    for investigator-initiated research that would preclude AHRQ from
    offering any new grants in this area.
        Additionally, in recent years, much of the funding for AHRQ has
    been derived from interagency transfers, rather than direct
    appropriations. The AAMC urges the subcommittee to provide the majority
    of the agency's funding through direct appropriations.
        Health Professions Funding.--The AAMC thanks the Subcommittee for
    the increased support in recent years for the health professions and
    nursing education programs under titles VII and VIII of the Public
    Health Service Act. These programs work to improve the diversity,
    distribution, and supply of the health professions workforce, with an
    emphasis on primary care and interdisciplinary training.
        The AAMC is pleased that the Patient Protection and Affordable Care
    Act (Public Law 111-148) updated and restructured the existing title
    VII and VIII programs to improve their efficiency, effectiveness, and
    accountability, and reauthorized them at funding levels that reflect
    the health workforce needs of the Nation. To enable the programs to
    perform most optimally and help achieve the goals of the legislation,
    the AAMC joins the Health Professions and Nursing Education Coalition
    (HPNEC) in support of an fiscal year 2011 appropriation of at least
    $600 million for the existing title VII and title VIII programs. This
    funding level will allow the programs to continue educating and
    training health professionals that are prepared to respond to the
    increased demand for healthcare services, improving access and quality
    of care across the country.
        In addition to the existing health professions programs, the
    legislation authorizes several new programs and initiatives under
    titles VII and VIII designed to mitigate health workforce challenges
    and expand the scope of the programs to additional fields. These new
    programs recognize the breadth of shortages across healthcare
    disciplines and aim to alleviate these existing and looming workforce
    shortages. The AAMC encourages the subcommittee to support these new
    programs with an investment that supplements the support for the core
    of title VII and VIII programs that have demonstrated their
    effectiveness.
        During their 40-year existence, the title VII and VIII programs
    have created a network of initiatives across the country that supports
    the training of many disciplines of health providers. These are the
    only Federal programs designed to create infrastructures at health
    professions schools and in their communities that facilitate customized
    training designed to bring the latest emerging national priorities to
    the populations at large and meet the healthcare needs of special,
    underserved populations. The AAMC urges the subcommittee to continue
    its commitment to the title VII and VIII health professions programs.
        National Health Service Corps.--The AAMC lauds the ambition of the
    Patient Protection and Affordable Care Act to provide up to $414
    million for the NHSC in fiscal year 2011 through discretionary
    appropriations and the HHS Secretary's new Community Health Center
    (CHC) Fund.
        The NHSC is widely recognized--both in Washington and in the
    underserved areas it helps--as a success on many fronts. It improves
    access to healthcare for the growing numbers of underserved Americans,
    provides incentives for practitioners to enter primary care, reduces
    the financial burden that the cost of health professions education
    places on new practitioners, and helps ensure access to health
    professions education for students from all backgrounds. Over its 39-
    year history, the NHSC has offered recruitment incentives, in the form
    of scholarship and loan repayment support, to more than 29,000 health
    professionals committed to serving the underserved.
        In spite of the NHSC's success, demand for health professionals
    across the country remains high. At a field strength of 4,760 in fiscal
    year 2009, the NHSC fell more than 24,000 practitioners short of
    fulfilling the need for primary care, dental, and mental health
    practitioners in Health Professions Shortage Areas (HPSAs), as
    estimated by HRSA. While the ``American Recovery and Reinvestment Act
    of 2009'' (Public Law 111-5) provided a temporary boost in annual
    awards, this increase must be sustained to help address the health
    professionals workforce shortage and growing maldistribution.
        The AAMC supports the President's fiscal year 2011 budget request
    ($169 million), which will ensure that the NHSC has access to
    additional dedicated funding through the HHS Secretary's CHC Fund. The
    AAMC further recommends that the subcommittee include report language
    directing the Secretary to provide enhanced funding for the NHSC over
    the fiscal year 2008 level, as directed under healthcare reform.
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

                FISCAL YEAR 2011 APPROPRIATIONS REQUEST SUMMARY

    ----------------------------------------------------------------------------------------------------------------
                                                                                              AANA fiscal year 2011
                                           Fiscal year 2010 actual  Fiscal year 2011 budget          request
    ----------------------------------------------------------------------------------------------------------------
    HHS/HRSA/BHPr Title VIII Advanced      Awaiting grant           Grant allocations not    $4 million for nurse
     Education Nursing, Nurse Anesthetist   allocations--in fiscal   specified.               anesthesia education
     Education Reserve.                     year 2009 awards
                                            amounted to
                                            approximately $3.5
                                            million.
    Total for Advanced Education Nursing,  $64.44 million for       $64.44 million for       $76.514 million for
     from Title VIII.                       Advanced Education       Advanced Education       Advanced Education
                                            Nursing.                 Nursing.                 Nursing
    Title VIII HRSA BHPr Nursing           $243,872,000...........  $243,872,000...........  $267,300,000
     Education Programs
    CDC/Division of Healthcare Quality                                                       $26 million
     and Promotion.
    HHS/Office of the Secretary..........                                                    $1 million
    ----------------------------------------------------------------------------------------------------------------

        The American Association of Nurse Anesthetists (AANA) is the
    professional association for the 44,000 Certified Registered Nurse
    Anesthetists (CRNAs) and student nurse anesthetists practicing today,
    representing over 90 percent of the nurse anesthetists in the United
    States. Today, CRNAs deliver approximately 32 million anesthetics to
    patients each year in the U.S. 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 in the 1980s. (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 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. Through continual improvements in research,
    education, and practice, nurse anesthetists are vigilant in our 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. 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 where
    more Medicare patients live.

          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
    $76.514 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 $76.514 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, particularly as we see more patients
    enter the system with the successful passage of health reform. More
    APRNs will be needed to fill the gap to ensure access to care. In
    addition, this funding provides a two-fold benefit for the nurse
    workforce. It 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.
        There continues to be high demand for CRNA workforce in clinical
    and educational settings. 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 2000-2009, 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 2,239 graduates in 2009. This growth is leveling off somewhat,
    but is expected to continue. However, 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 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, 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. Third, 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 The Nursing Community and the Americans for Nursing
    Shortage Relief (ANSR) Alliance in support of the Subcommittee
    providing a total of $267.3 million in fiscal year 2011 for nursing
    shortage relief through title VIII. This amount is a modest 10 percent
    increase over fiscal year 2010 levels and necessary in a time of
    expanded access through health reform. As more patients enter the
    system, it's imperative there are enough nurses to care for them. AANA
    asks that of the $267.3 million, $76.514 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 2010
    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

        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 2011:
      --$26 million for the Centers for Disease Control and Prevention's
            (CDC) Division of Healthcare Quality and Promotion to address
            outbreaks and promote innovative ways to adhere to injection
            safety and infection control guidelines. $5 million would be
            used to support the CDC's efforts around provider education and
            patient awareness activities; and
      --$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 outpatient settings with
            the development of an action plan to reduce HAIs in outpatient
            settings with a specific focus on injection safety.
                                     ______

       Prepared Statement of the American Academy of Nurse Practitioners

        The American Academy of Nurse Practitioners is the full service
    organization representing more than 135,000 nurse practitioners
    throughout the United States. This testimony speaks to the need for
    continued and increased Federal funding for nurse practitioner
    educational programs and traineeships for the coming fiscal year.
        As the subcommittee knows, nurse practitioners are highly qualified
    healthcare providers who have demonstrated their ability and interest
    in providing primary care to individuals and families in both rural and
    urban settings, regardless of age, occupation or income. The quality of
    their care has been well documented over the years. With their advanced
    preparation, they are able to manage the medical and health problems
    seen in the primary care and acute care settings in which they work.
        Nurse practitioners constitute an effective body of primary care
    providers that may be utilized at a cost savings in both fee for
    service and managed care arenas in this country. Savings to the Federal
    government of greater than $100,000,000 per year in the Medicare
    program alone are estimated when full utilization of nurse
    practitioners is implemented. Likewise, managed care data has
    demonstrated cost savings among patients seen by nurse practitioners
    when compared to similar patients being cared for by physicians.
        Other cost savings that can be realized by the Government when
    nurse practitioners are appropriately utilized, include savings due to
    reductions in emergency room visits and hospitalizations and savings
    associated with the treatment of illness in its early stages. Studies
    in both fee for service and managed care have been conducted that
    demonstrate cost savings in diagnostic testing, prescribing, and
    hospitalizations and emergency room use when these two groups of
    providers are utilized to provide primary care to populations of all
    ages.
        Nurse practitioner specialties include family, adult, pediatric,
    women's health, and gerontology. Their services include obtaining
    medical histories, performing physical examinations, ordering,
    performing, supervising and interpreting diagnostic tests, diagnosing
    and treating acute episodic and chronic illnesses including the
    prescription of medications and other nonpharmacologic treatments, and
    appropriate referral to other sources of care. In addition, they are
    skilled in the areas of health promotion and disease prevention which
    include health education, screening, and counseling for patients of all
    ages.
        Nurse practitioners provide care in both rural and urban settings,
    in community health centers, public health clinics, hospitals and
    hospital outpatient clinics, Indian Health Service and National Health
    Service Corps sites as well as other freestanding primary care
    settings. According to data collected by the American Academy of Nurse
    Practitioners, more than 70 percent of nurse practitioners provide
    primary care and more than 50 percent of their patients have family
    incomes in the poverty range.
        In order to guarantee the proper preparation of nurse
    practitioners, assistance in the development of high-quality programs
    continues to be needed across the country. The funding for such
    programs has always been limited, and should always be more. The value
    and worth of such funding continues to be undisputable.
        The sums of money described here are but a drop in the bucket
    compared to investments made by the Federal Government to underwrite
    the cost of preparing other medical professionals. Yet in the face of
    significant nursing shortages, the existence of more than 40,000,000
    people with no health insurance and the continued lack of primary care
    providers in this country increases in this funding are obviously
    needed. Without these increases, additional barriers to the effective
    utilization of the most cost-effective primary care providers in our
    healthcare system are created.
        Likewise, traineeship monies are being utilized by students in all
    50 States and the District of Columbia. These monies are of particular
    importance in the recruitment of nurse practitioners. Current funds
    fall far short of the mark for assisting in the preparation of these
    important, cost-effective healthcare providers in the system. These
    appropriations help to reduce barriers for many students desiring to
    become nurse practitioners. Surveys of nurse practitioners have shown
    this investment to be a good one in terms of assisting students who
    otherwise might not be able to return to school, and in terms of adding
    providers who care for the rural and urban underserved in this country.
        The recommended increase of 10 percent to the current funding
    levels in the advanced practice line of title VIII will only begin to
    make a dent in meeting the unmet healthcare needs of today's
    populations. In light of the current and future needs for primary care
    providers, it is obvious that increasing appropriations for nurse
    practitioner education, traineeships and program exploration will be a
    wise investment.
        We thank the members of the Appropriations Committee for their
    efforts in behalf of nurse practitioners and the patients they serve.
    We know you recognize the value of our services and the need for
    utilizing us in the provisions of quality, cost-effective healthcare.
    It is obvious that we can be part of the solution to the current
    shortage of healthcare providers in this country and we are asking for
    your help to facilitate the process. If there is anything we can do to
    provide further information or assistance regarding this issue, please
    feel free to call on us.
                                     ______

          Prepared Statement of the American Academy of Ophthalmology

                               EXECUTIVE SUMMARY

        The American Academy of Ophthalmology requests fiscal year 2011 NIH
    funding at $35 billion, which reflects a $3 billion increase more than
    President Obama's proposed funding level of $32 billion. Funding at $35
    billion, which reflects NIH's net funding levels in both fiscal year
    2009 and fiscal year 2010, ensures it can maintain the number of multi-
    year investigator-initiated research grants, the cornerstone of our
    Nation's biomedical research enterprise.
        The vision community commends Congress for $10.4 billion in NIH
    funding in the American Recovery and Reinvestment Act (ARRA), as well
    as fiscal year 2009 and fiscal year 2010 funding increases that enabled
    NIH to keep pace with biomedical inflation after 6 previous years of
    flat funding that resulted in a 14 percent loss of purchasing power.
    Fiscal year 2011 NIH funding at $35 billion enables it to meet the
    expanded capacity for research--as demonstrated by the significant
    number of high-quality grant applications submitted in response to ARRA
    opportunities--and to adequately address unmet need, especially for
    programs of special promise that could reap substantial downstream
    benefits, as identified by NIH Director Francis Collins, M.D., Ph.D. in
    his top five priorities. As President Obama has stated repeatedly,
    including at a visit to the NIH in September 2009, biomedical research
    has the potential to reduce healthcare costs, increase productivity,
    and ensure the global competitiveness of the United States.
        The Academy requests that Congress improve upon the President's
    proposed 2.5 percent NEI increase--the second smallest increase of all
    Institutes and Centers--especially if it does not increase overall NIH
    funding above the President's request.
        In 2009, Congress spoke volumes in passing S. Res. 209 and H. Res.
    366, which acknowledged NEI's 40th anniversary and designated 2010-2020
    as The Decade of Vision, in which the majority of 78 million baby
    boomers will turn 65 years of age and face greatest risk of aging eye
    disease. This is not the time for a less-than-inflationary increase
    that nets a loss in NEI's purchasing power, which eroded by 18 percent
    in the fiscal year 2003-2008 timeframe. NEI-funded research is
    resulting in treatments that save vision and restore sight, which can
    reduce healthcare costs, maintain productivity, ensure independence,
    and enhance quality of life.
        Fiscal year 2011 NIH funding at $35 billion enables the NEI to
    build upon the impressive record of basic and clinical collaborative
    research that meets NIH's top five priorities and was funded through
    fiscal year 2009-2010 ARRA and increased ``regular'' appropriations.
        NEI's research addresses the pre-emption, prediction, and
    prevention of eye disease through basic, translational, epidemiological
    and comparative effectiveness research which also address the top five
    NIH priorities, as identified by Dr. Collins: genomics, translational
    research, comparative effectiveness, global health, and empowering the
    biomedical enterprise. NEI continues to be a leader within the NIH in
    elucidating the genetic basis of ocular disease--NEI Director Paul
    Sieving, M.D., Ph.D., has reported that one-quarter of all genes
    identified to date through collaborative efforts with the National
    Human Genome Research Institute (NHGRI) are associated with eye disease
    or visual impairment.
        NEI received $175 million of the $10.4 billion in NIH ARRA funding.
    As a result, NEI's total funding levels in the fiscal year 2009-2010
    timeframe were $776 million and $794.5 million, respectively. In fiscal
    year 2009, NEI made 333 ARRA-related awards, the majority of which
    reflect investigator-initiated research that funds new science or
    accelerates ongoing research, including 10 Challenge Grants. Several
    examples of research and the reasons why it is important, include:
      --Biomarker for Neovascular Age-related Macular Degeneration (AMD).--
            Researchers will use a recently discovered biomarker for
            choroidal neovascularization (CNV)--the growth of abnormal
            blood vessels into the retina and responsible for 90 percent of
            vision loss associated with AMD--to develop an early detection
            method to minimize vision loss. Why is this important? AMD is
            the leading cause of vision loss in the United States,
            especially in the elderly.
      --Cellular Approach to Treating Diabetic Retinopathy (DR).--
            Researchers propose to develop a clinical treatment for
            diabetic retinopathy--in which diabetes damages small blood
            vessels in the retina, causing them to leak--that uses stem
            cells from the patient's own blood that have been activated
            outside of the body and then returned to repair damaged vessels
            in the eye. Why is this important? DR is the leading cause of
            vision loss in younger Americans and its incidence is
            disproportionately higher in African Americans, Latinos, and
            Native Americans.
      --Small Heat Shock Proteins as Therapeutic Agents in the Eye.--
            Researchers propose to develop new drugs to prevent or reverse
            blinding eye diseases, such as cataract (clouding of the lens),
            that are associated with the aggregation of proteins. Research
            will focus on the use of small ``heat shock'' proteins that
            facilitate the slow release and prolonged delivery of targeted
            macromolecules to degenerating cells of the eye. Why is this
            important? Delivering effective, long-lasting therapies through
            a minimally invasive route into the eye is a major challenge.
      --Identification of Genes and Proteins That Control Myopia
            Development.--Researchers propose to identify targets that will
            facilitate development of interventions to slow or prevent
            myopia (nearsightedness) development in children. Identifying
            an appropriate myopia prevention target can reduce the risk of
            blindness and reduce annual life-long eye care costs. Why is
            this important? More than 25 percent of the U.S. population has
            myopia, costing $14 billion annually, from adolescence to
            adulthood.
      --Comparison of Interventions for Retinopathy of Prematurity (ROP).--
            In animal studies, researchers will simulate Retinopathy of
            Prematurity--a blinding eye disease that affects premature
            infants--and study novel treatments that involve modulating the
            metabolism of the retina's rod photoreceptors. Why is this
            important? ROP affects 15,000 children a year, about 400-600 of
            whom progress to blindness, at an estimated lifetime cost for
            support and unpaid taxes of $1 million each.
      --The NEI Glaucoma Human Genetics CollaBORation, NEIGHBOR.--This
            research network, in which seven U.S. teams will lead genetic
            studies of glaucoma, may lead to more effective diagnosis and
            treatment. Researchers were primarily funded through ARRA
            supplements. Why is this important: Glaucoma, a complex
            neurodegenerative disease that is the second leading cause of
            preventable blindness in the United States, often has no
            symptoms until vision is lost.
      --Comparative Effectiveness of Interventions for Primary Open Angle
            Glaucoma (POAG).--Researchers will evaluate existing data on
            the effectiveness of various treatment options for primary open
            angle glaucoma--many emerging from past NEI research. Why is
            this important? POAG is the most common form of the disease,
            which disproportionately affects African Americans and Latinos.
        In addition to ARRA funding, the ``regular'' appropriations
    increases in fiscal year 2009-2010 enabled NEI to continue to fund key
    research networks, such as:
      --The African Descent and Glaucoma Evaluation Study (ADAGES), is
            designed to identify factors accounting for differences in
            glaucoma onset and the rate of progression between individuals
            of African and European descent.
      --The Diabetic Research Clinical Research Network's (DRCR) initiation
            of new trials comparing the safety and efficacy of drug
            therapies as an alternative to laser treatment for diabetic
            macular edema and proliferative diabetic retinopathy.
      --The Neuro-Ophthalmology Research Disease Investigator Consortium
            (NORDIC), which will lead multi-site observational and
            treatment trials involving nearly 200 community and academic
            practitioners, to address the risks, diagnosis and treatment of
            visual dysfunction due to increased intracranial pressure and
            thyroid eye disease.
        The unprecedented level of fiscal year 2009-2010 vision research
    funding is moving our Nation that much closer to the prevention of
    blindness and restoration of vision. With an overall NIH funding level
    of $35 billion, which translates to an NEI funding level of $794.5
    million, the vision community can accelerate these efforts, thereby
    reducing healthcare costs, maintaining productivity, ensuring
    independence and enhancing quality of life.
        If Congress does not increase fiscal year 2011 NIH funding above
    the President's request, it is even more vital to improve upon the
    proposed 2.5 percent increase for NEI.
        The NIH budget proposed by the administration and developed by
    Congress during the very first year of the Congressionally-designated
    Decade of Vision should not contain a less-than-inflationary increase
    for NEI due to the enormous challenges it faces in terms of the aging
    population, the disproportionate incidence of eye disease in fast-
    growing minority populations and the visual impact of chronic disease
    (e.g., diabetes). If Congress is unable to fund NIH at $35 billion in
    fiscal year 2011 (NEI level of $794.5 million) and adopts the
    President's proposal, the 2.5 percent increase in funding must be
    increased to at least an inflationary level of 3.2 percent to prevent
    any further erosion in NEI's purchasing power. NEI funding is an
    especially vital investment in the overall health, as well as the
    vision health, of our Nation. It can ultimately delay, save and prevent
    health expenditures, especially those associated with the Medicare and
    Medicaid programs, and is therefore a cost-effective investment.
        Vision loss is a major public health problem: increasing healthcare
    costs, reducing productivity, diminishing life quality.
        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 due to its disproportionate incidence in minority
    populations and as a co-morbid condition of chronic disease such as
    diabetes.
        Although 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 combined impacts 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.
                  about the american academy of ophthalmology
        The American Academy of Ophthalmology is a 501c(6) educational
    membership association. The Academy is the largest national membership
    association of eye M.D.s with more than 27,000 members, over 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 Academy members.
                                     ______

       Prepared Statement of the American Academy of Physician Assistants

        On behalf of the nearly 80,000 clinically practicing physician
    assistants in the United States, the American Academy of Physician
    Assistants is pleased to submit comments on fiscal year 2011
    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 $330 million for title VII programs in fiscal year 2011,
    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 over 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 1990-2009 demonstrates that PAs who
    have graduated from PA educational programs supported by title VII are
    67 percent more likely to be from underrepresented minority populations
    and 47 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 39 percent between 2008 and 2018. 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 2011 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 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 $330 million in funding for fiscal year 2011,
    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 2011 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.
        The Alliance for Aging Research supports the continuation and
    expansion of NIH research activities which affect tens of millions of
    older Americans. The NIA leads national research efforts within the NIH
    to better understand the aging process and ways to better maintain the
    health and independence of Americans as they age. Research on healthy
    aging has never been more critical for so many Americans as the first
    of the baby boomers will turn 65 in 2011. Presently, there are about 36
    million Americans age 65 and older and this group is expected to double
    in size within the next 25 years. By 2050, an estimated 19.4 million
    Americans will be over the age of 85. Healthcare spending in the United
    States is growing, and by 2018 national healthcare spending is
    projected to be about $4.4 trillion and account for 20.3 percent of
    GDP, according to Centers for Medicare and Medicaid Services.
        Many diseases of aging are expected to become more widespread as
    the number of older Americans increases. The number of Americans age 65
    and older with Alzheimer's disease is projected to more than double by
    2030. A recent report in the Journal of Clinical Oncology projected
    cancer incidence will increase by about 45 percent from 2010-2030,
    accounted for largely by cancer diagnoses in older Americans and
    minorities, and by 2030, people aged 65 and older will represent 70
    percent of all cancer diagnoses in the United States. Currently, the
    average 75-year old has three chronic health conditions and takes five
    prescription medications. Six diseases--heart disease, stroke, cancer,
    diabetes, Alzheimer's and Parkinson's diseases--cost the United States
    more than $1 trillion each year. The rising tide of chronic diseases of
    aging threatens to deluge the U.S. healthcare system in the coming
    years.
        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. According to a 2005 AHRQ
    report, up to $2.5 billion per year could be saved by preventing
    diabetes-related hospitalizations with appropriate primary care, and
    much of the savings would come from Medicare and Medicaid. Osteoporosis
    is estimated to cost the United States $25.3 billion per year by 2025
    unless discoveries are made to better treat and prevent the disease.
    According to an Alzheimer's Association report from 2004, research
    breakthroughs that slow the onset and progression of Alzheimer's
    disease could yield annual Medicare savings of $51 billion by 2015 and
    $126 billion by 2025. Research which leads to a better understanding of
    the aging process and human vulnerability to age-related diseases could
    help Americans live longer, more productive lives, and help reduce the
    need for care to manage costly chronic diseases.
        In fiscal year 2009, the NIA, which supports a range of genetic,
    biological, clinical, social and economic research related to aging and
    the diseases of the elderly, oversaw approximately 1,900 research
    projects. Through the Division of Aging Biology (DAB), the NIA funds
    research focused on understanding and exploiting the mechanisms
    underlying the aging process. Research supported by the DAB 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. Some studies supported by the DAB
    assess the beneficial effects of reducing caloric intake in animals.
    Intramural and extramural research is ongoing 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 has supported grants in recent years to examine public
    health concerns caused by the rising obesity epidemic. In particular,
    NIA's Division of Behavioral and Social Science Research funded
    projects to investigate the role social networks play in influencing an
    individual's food choices, acceptability of being overweight, and how
    those networks might be modifiable to slow the spread of obesity; as
    well as those to explore how the rapid increase in obesity will
    negatively affect U.S. gains in life expectancy. Investigators
    supported by the Division of Geriatrics and Clinical Gerontology have
    focused heavily on the central role exercise plays in improving the
    health of older adults, reducing health risks associated with diabetes
    and cardiovascular disease, and lowering the risk of death by
    increasing a individual's fitness level. Results from studies such as
    these will not only yield important information for use in the care of
    the elderly, but also for promoting healthier behavior by the larger
    U.S. population.
        The NIA also participates in collaborations on disease-specific
    research aimed at preventing, diagnosing, and more effectively treating
    age-related illnesses. 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
    clinical trials for Alzheimer's therapies. 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 (DPP), a large nationwide clinical
    study of adults at high risk for diabetes, funded in part by the NIA,
    showed that lifestyle intervention (intensive training on diet,
    physical activity and behavior changes with the goal of weight loss)
    reduced the development of diabetes by 58 percent over several years.
    The risk reduction was even greater, 71 percent, among adults aged 60
    years or older. Taking an oral diabetes drug reduced the development of
    diabetes among participants by 31 percent, but was less effective in
    adults older than age 45 compared to younger adults. This landmark
    research study identified effective interventions for adults with pre-
    diabetes and showed the development of diabetes was not necessarily
    inevitable but could be slowed or prevented in this group by losing a
    modest amount of weight through diet and exercise. More recent studies,
    both completed and ongoing, have further examined DPP data and continue
    to build on the findings from the diverse group of study participants.
    The Diabetes Prevention Program Outcomes Study is examining the long
    term risk reduction effects of the DPP intervention and the clinical
    course of new-onset diabetes and complications in participants, with
    attention to differences among minority populations and gender groups.
    Shedding light on differences between these groups could have wide-
    reaching implications for millions of Americans at risk for diabetes
    and may assist in the creation of more effective interventions.
        Eighty percent of all the nonprofit medical research in the United
    States is funded by the NIH. However, the unfortunate reality is that
    shrinking budgets have impeded progress. Aging is a field of research
    whose progress has been hampered by stagnant funding. In part the
    scarcity of resources has resulted in a decline of the overall success
    rate for NIH research grant applications. The effect of this has been
    reluctance on behalf of new investigators to submit truly ground-
    breaking research proposals for consideration. 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. At its lowest point only one in four
    research proposals could be funded by the NIH. In recognition of this
    downward trend, last February President Obama signed into law the
    American Recovery and Reinvestment Act of 2009 (ARRA), which
    appropriated $10.4 billion in funding to the NIH to be used
    expeditiously in fiscal year 2009 and fiscal year 2010. That March, the
    NIH budget for fiscal year 2009 was increased 3.2 percent more than
    fiscal year 2008 to $30.3 billion. This was a much needed boost across
    the NIH Institutes for critical medical research to benefit Americans,
    including just more than 170 research grants funded by the NIA in
    ARRA's first year.
        Promising areas of research targeted by the NIA to receive ARRA
    funds include those to identify additional risk factor genes associated
    with Alzheimer's disease, discovering improved diagnostic tools,
    possible biomarkers, and therapies. ADNI will receive the most
    significant amount of stimulus funding to further groundbreaking
    research that will enable experts to track changes in living brains as
    older adults as they transition from normal cognitive aging to the
    early stages of Alzheimer's disease. The overall impact of this
    investment will be to increase knowledge of the sequence and timing of
    events leading up to disease onset and to develop better methods of
    early detection and monitoring of the disease. Another grant awarded
    funding through ARRA will develop new technologies, called biosensors,
    to follow protein folding in cells. Proper protein folding
    (proteostasis) is important to health. Researchers believe that protein
    folding is affected by age. If proteins are formed incorrectly, or they
    misfold normal cell function is disrupted. These problems are thought
    to cause disease. The biosensors created with ARRA funds will help
    monitor aging and age-related disease by focusing on patterns of
    protein folding. ARRA funds have also been awarded to investigators who
    will study the effects of rapamaycin, a compound that mimics caloric
    restriction, on models of human diseases in mice. Models of Alzheimer's
    disease, atherosclerosis, cardiovascular disease, Parkinson's disease,
    kidney disease and cancer will be utilized in this project. The
    investigators will ultimately seek to determine if the quality of life
    for the mice has improved and if the age-related diseases have been
    slowed or reduced over a 2-year period.
        The ARRA funding begins to make up for flat budgets and unfunded
    research proposals that have occurred in recent years. However,
    research at the NIH cannot be sustained and will not flourish in the
    long term without a steady increase in appropriations which, at
    minimum, keeps pace with inflation. A slowdown in NIH funding will have
    a devastating impact on the rate of basic discovery, innovation and the
    development of interventions which could have major health benefits for
    the burgeoning population of older Americans. The Alliance for Aging
    Research supports funding the NIH at $35 billion in fiscal year 2011
    with a minimum of $1.14 billion in funding for the NIA specifically.
    This level of support would allow the NIH and the NIA to adequately
    fund new and existing research projects, accelerating progress toward
    findings which could prevent, treat, slow the progression or even
    possibly cure conditions related to aging. With the silver tsunami on
    the near horizon, an increased investment in NIA's research activities
    has never been more necessary or had such potential to impact so many
    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 2011 appropriations for
    the NIH and we would be happy to furnish additional information upon
    request.
                                     ______

               Prepared Statement of the American Brain Coalition

    Introduction
        The National Institutes of Health (NIH) is the world's leader in
    medical discoveries that improve people's health and save lives. NIH-
    funded scientists at universities and research centers throughout the
    Nation investigate ways to prevent, treat, and even cure the complex
    diseases of the brain. Because there is much work still to be done, the
    American Brain Coalition (ABC) writes to ask for the Senate
    Appropriations Committee's continued support for increased biomedical
    research funding at NIH.
    ABC
        ABC is a nonprofit organization that seeks to reduce the burden of
    brain disorders and advance the understanding of the functions of the
    brain. The ABC, made up of more than 50 member organizations, brings
    together afflicted patients, the families of those that suffer, the
    caregivers, and the professionals that research and treat diseases of
    the brain.
        The brain is the center of human existence, and the most complex
    living structure known. As such, there are thousands of brain diseases
    from Rett Syndrome and autism to mental illness and Parkinson's
    disease. ABC, unlike any other organization, brings together people
    affected by all diseases of the brain.
        The ABC is working to raise public awareness and support for
    diseases of the brain. Fifty million Americans--our relatives, friends,
    neighbors, and your constituents--are affected by diseases of the
    brain. This number does not include the millions more family members
    whose lives are affected as they care for those who suffer. Our goal is
    to be a united voice for these patients, and to work with Congress and
    the administration to alleviate the burden of brain disease. A large
    part of that goal involves support for NIH research.
    Thank You for Your Support
        ABC would like to thank the members of this subcommittee and the
    Senate for its support for the $10 billion provided to NIH in the 2009
    economic stimulus package. This funding provided the opportunity for a
    substantial number of 2-year research grants and infrastructure
    projects in every State of the Nation to move forward and enhance our
    understanding of an array of physical and mental health concerns.
        Progress in the fields of addiction, alcoholism, Parkinson's
    disease, and stroke has already been made by scientists funded through
    ARRA funding. One such investigator is studying how to improve motor
    function following stroke. Another investigator is using specially
    designed video games to understand the cognitive effects of autism, in
    order to develop behavioral or drug treatments. Please visit http://
    bit.ly/a0g8aA to learn more about the progress made.
        More than 1,900 new investigators received ARRA grant funding.
    Scientists were inspired to do more research and patients suffering
    from debilitating neurological and psychiatric disorders were given
    hope, thanks to your generous support of ARRA.
    Congressional Support Accelerates Discovery
        In the late 1990s, Congress made a commitment to double the budget
    of the NIH over the course of 5 years. The primary goal for the added
    funds was to discover better treatments and cures for human disease.
    Congress delivered on its promise, and scientists have amassed a wealth
    of medical knowledge. Today, researchers have a greater understanding
    of how the brain and nervous system function due to NIH-funded
    research.
        Many recent scientific discoveries, including those in neurology,
    psychiatry, and behavioral research have begun to show their potential.
    Insights into the biology of schizophrenia, epilepsy, Alzheimer's, and
    other disorders have led to the development of enhanced diagnostic
    techniques, better prevention methods, and more effective treatments.
    Simply put: the result of congressional support for research leads to
    improved patient care.
    Today's Research: Hope for the Future
        Today's research is the foundation for future breakthroughs. The
    Federal Government's investment in research must be sustained in order
    to translate today's scientific findings into further bedside
    treatments, and the ABC supports NIH in its entirety. Recent
    discoveries, such as those listed below, are a direct result of robust
    funding for the NIH.
      --The development of drugs that reduce the severity of symptoms for
            those suffering with multiple sclerosis and Parkinson's
            disease.
      --The identification of stroke treatment and prevention methods.
      --The discovery of a new class of anti-depressants that produce fewer
            side effects than their predecessors.
      --The creation of new drugs to help prevent epileptic seizures.
      --The expansion of treatments for the psychotic symptoms of
            schizophrenia.
        My own field of research concerns schizophrenia, a devastating
    brain disorder that affects 1 percent of the population but is the
    seventh most costly medical illness to our society because of its life-
    long disability. Basic brain research funded by the National Institute
    of Mental Health has transformed our understanding of the disorder and
    illuminated new targets for therapeutic intervention that affect
    symptoms untouched by existing drugs.
    Research Improves Health and Fuels the Economy
        Diseases of the nervous system pose a significant public health and
    economic challenge, affecting nearly 1 in 3 Americans at some point in
    life. Improved health outcomes and positive economic data support the
    assertion that biomedical research is needed to improve public health
    today and save money tomorrow.
        Not only does research save lives and fuel today's economy, it is
    also a wise investment in the future. For example, 5 million Americans
    suffer from Alzheimer's disease today, and the cost of caring for these
    people is staggering. Medicare expenditures are $91 billion each year,
    and the cost to American businesses exceeds $60 billion annually,
    including lost productivity of employees who are caregivers. As the
    baby boom generation ages and the cost of medical services increases,
    these figures will only grow. Treatments that could delay the onset and
    progression of the disease by even 5 years could save $50 billion in
    healthcare costs each year. Research funded by the NIH is critical for
    the development of such treatments. The cost of investing in NIH today
    is minor compared to both current and future healthcare costs.
        Additionally, it is estimated that each billion of dollars of NIH
    funding generates 15,000 to 20,000 well-paying jobs that can't be sent
    offshore. Science funding also generates more than twice as much in
    State and local economic output. A strong Federal investment in
    research can assist your State in maintaining a biomedical research
    foundation that attracts companies and investors. For instance, in
    fiscal year 2007, NIH dollars generated more than $50 billion in new
    State business.
        Strong science funding can bolster the economy today and improve
    our Nation's long term health and competitiveness tomorrow. Robust
    research and development investment remains the key to America's long-
    term global competitiveness. NIH funding serves as the basis for future
    innovation and industries such as pharmaceutical, medical device, and
    biotechnology.
    Fiscal Year 2011 Recommendation
        ABC supports $35 billion for the National Institutes of Health in
    fiscal year 2011. This represents the new functional capacity funded by
    the annual appropriations process and the American Recovery and
    Reinvestment Act. In addition, it will help the NIH to achieve its
    broad research goals and provide hope for the millions of Americans
    affected with neurological and psychiatric disorders, while
    strengthening the economy and creating jobs throughout the country.
        There is still much work to be done to uncover the mysteries of the
    brain. Fiscal year 2011 provides Congress with the opportunity to renew
    its past commitment to health funding as a national priority.
                                     ______

            Prepared Statement of the American College of Cardiology

        The American College of Cardiology (ACC) appreciates the
    opportunity to provide the subcommittee with recommendations for fiscal
    year 2011 funding for cardiovascular research and prevention. The ACC
    is a more than 38,000 member, non-profit professional medical society
    and teaching institution whose mission is to advocate for quality
    cardiovascular care--through education, research promotion, development
    and application of standards and guidelines--and to influence
    healthcare policy.
        Heart disease is America's number one killer and a major cause of
    permanent disability. Nearly 1 in 3 adults in the United States suffers
    from heart disease. Heart disease and stroke will cost the United
    States an estimated $503.2 billion in 2010, including healthcare costs
    and lost productivity.
        The death rates attributable to cardiovascular disease actually
    have declined due to advances in science through diagnostic tests, drug
    and device therapies, surgical innovations, enhanced emphasis on
    prevention, and innovative public education programs. Federal research
    provided for many of these advances that improve understanding of the
    prevention and treatment of cardiovascular disease, leading to better
    outcomes and increased quality of life for patients.

                ACC FUNDING RECOMMENDATIONS FOR FISCAL YEAR 2011

        As the subcommittee considers its appropriations for programs
    within the Department of Health and Human Services, the ACC urges
    support of the following recommendations.
    National Institutes of Health (NIH)
        The ACC supports an appropriation of $35.2 billion for the National
    Institutes of Health (NIH). This funding level will allow the NIH to
    build on momentum achieved from investments from the American Recovery
    and Reinvestment Act (ARRA). The NIH currently invests only 4 percent
    of its budget on heart research; the ACC urges NIH to invest a higher
    percentage of its budget to heart research.
    National Heart, Lung, and Blood Institute (NHLBI)
        The ACC supports an appropriation of $3.514 billion for the
    National Heart, Lung, and Blood Institute (NHLBI). The NHLBI does
    critical research into the causes, diagnosis, and treatment of heart
    disease.
    Agency for Healthcare Research and Quality (AHRQ)
        The ACC supports the President's budget request of $611 million for
    the Agency for Healthcare Research and Quality (AHRQ). The ACC supports
    the recent increases in funding for AHRQ's comparative effectiveness
    research program, and also believes AHRQ's health services research
    related to healthcare costs, quality, and access are critically
    important.
    CDC Heart Disease and Stroke Prevention
        The ACC supports an appropriation of $76.221 million for the
    Centers for Disease Control and Prevention (CDC) Division for Heart
    Disease and Stroke Prevention. These public education efforts are
    helping to reduce blood pressure and cholesterol, educate about heart
    disease and stroke signs and symptoms, enhance emergency response and
    quality care, and end treatment disparities.
        The ACC also supports an appropriation of $37.087 million for CDC's
    WISEWOMAN program. This program screens uninsured and under-insured
    low-income women ages 40 to 64 for heart disease and stroke risk and
    those with abnormal results receive counseling, education, referral and
    follow up.
    HRSA Rural and Community AED Program
        The ACC supports an appropriation of $8.927 million for the Health
    Resources and Services Administration (HRSA) Rural and Community Access
    to Emergency Devices Program, which would restore it to its fiscal year
    2005 level when 47 States received resources from the initiative. This
    program provides competitively awarded grants to States to purchase
    automated external defibrillators (AEDs), train lay rescuers and first
    responders in their use, and place them in public areas where sudden
    cardiac arrests are likely to occur. In 2009 only ten states received
    funding for this initiative.
    NHLBI and CDC: Congenital Heart Disease Research and Surveillance
        The ACC is pleased that the recently enacted ``Patient Protection
    and Affordable Care Act'' includes provisions to enhance and expand the
    infrastructure to track the epidemiology of congenital heart disease
    (CHD) and to conduct and support research on it. The ACC as well as the
    Adult Congenital Heart Association, Mended Little Hearts and Children's
    Heart Foundation, stand ready to work with the subcommittee to advance
    these policies.
        Congenital heart defects are the most common birth defect in the
    United States and are a leading cause of child mortality. The success
    of childhood cardiac intervention has created a new chronic disease--
    CHD. Those who receive successful intervention will need life-long
    special cardiac care and face high rates of heart failure, rhythm
    disorders, stroke and sudden cardiac death. Thanks to the increase in
    survival, the CHD population is rising by 5 percent a year; there are
    about 800,000 children and 1 million adults in the United States now
    living with CHD.
        Despite the prevalence and seriousness of the disease, data
    collection and research are limited. Federal funding support for CHD
    surveillance through CDC and research through NHLBI is necessary to
    help prevent premature death and disability in this rapidly growing and
    severely underserved population.

                      CARDIOVASCULAR DISEASE RESEARCH GAPS

        As the healthcare system evolves towards better integration of
    health information technology (HIT), clinical decision support tools,
    and performance measurement, the need for meaningful clinical practice
    guidelines is essential. The American College of Cardiology Foundation
    (ACCF) and the American Heart Association (AHA) have a long history in
    the development of clinical practice guidelines, and have close to 20
    guidelines on a range of cardiovascular topics. The guidelines are
    developed through a rigorous, evidence-based methodology, including
    multiple layers of review and expert interpretation of the evidence on
    an ongoing, regular basis.
        Many clinical research questions remain unanswered or understudied,
    however. The ACC has identified knowledge gaps for cardiovascular
    disease that if addressed, have potential to positively impact patient
    outcomes, costs, and the efficiency of care delivery. A Federal
    investment through the NHLBI and AHRQ to answer the following questions
    will help to better narrow the target population who can benefit from
    treatment and therefore increase the efficacy and efficiency of
    patient-centered care delivery.
      --What is the effect of common cardiovascular therapies on elderly
            populations whose metabolism and kidney function are lower and
            may not respond to medications in the same way as the younger
            patients typically included in clinical trials?
      --What is the effect of common cardiovascular therapies on patients
            with multiple other diseases/conditions?
      --What is the effect of common cardiovascular therapies on women?
            What are signs and risk factors for cardiovascular disease in
            women?
      --What are the best approaches to increasing patient compliance with
            existing therapies?
      --What screening and risk models (existing or new) could further
            define who will benefit from various therapies?
      --What are the optimal management strategies for anticoagulation and
            antiplatelet agents in heart attack patients, patients with
            stents, and atrial fibrillation patients to maximize benefit
            and reduce bleeding risks?
      --What are the best approaches to managing complex but understudied
            cardiovascular topics such as congenital heart disease,
            valvular heart disease, and hypertrophic cardiomyopathy? These
            topics have become areas of higher research interest as
            techniques have developed to extend the lives of patients with
            these disorders.
      --What are the risks and benefits of common off-label uses of widely
            used therapies and procedures?
      --What are the risks and benefits of various cardiovascular screening
            protocols, such as those for imaging methods used to correctly
            identify patients who will benefit from surgical, endovascular,
            and/or medical interventions?
      --What are the best catheter-based techniques to increase treatment
            success and reduce complications for both coronary and cardiac
            rhythm procedures?
      --What are the effects of nutrition, environment and genetics on the
            occurrence of congenital heart defects?
        The above list of topics is not exhaustive but gives an overview of
    some of the themes of the evidence gaps that exist across the ACCF/AHA
    guidelines. In addition to specific clinical research topics, the ACCF
    recommends funding to help address structural issues that could help
    identify, prioritize, and interpret research findings over the long
    term.
      --The NIH and or AHRQ should fund more trials of direct comparison of
            clinical effectiveness between pharmacological and other
            therapies. Without these important trials, the current emphasis
            on promoting comparative effectiveness will be founded upon
            efficacy trials and not effectiveness.
      --The NHLBI should work with the clinical cardiology community to
            proactively design clinical trials to address unanswered
            clinical questions and identify methods that allow for greater
            comparability among studies. NHLBI should work with ACCF and
            the AHA to develop an evidence model that would drive future
            research initiatives based on current evidence gaps in the
            guidelines; and
      --NIH should fund the development of a robust informatics
            infrastructure across Institutes to process research evidence.
            Studies should be designed such that their results could be
            ``fed'' into a computer model that would provide additional
            insights for developers of clinical recommendations.
      --NIH and or AHRQ should fund studies of patient preference and
            values.
          arra in action: collaborating to improve cardiovascular care
        In September 2009, the ACC was pleased to be awarded two Federal
    grants under ARRA. The ACC has applied for three others, in addition to
    serving as a subcontractor on several other grant applications.
    Grand Opportunity Grants
                Comparative Effectiveness of PCI versus CABG Grant
        The NHLBI awarded a Grand Opportunity grant to the ACC in
    partnership with the Society of Thoracic Surgeons (STS) to study the
    comparative effectiveness of the two forms of coronary
    revascularization; percutaneous coronary intervention (PCI) and
    coronary artery bypass graft (CABG) surgery (Award Number 1RC2HL10148).
    Now entering the second half of this 2 year award period, the study is
    comparing these two cardiac procedures using existing databases from
    the ACC and STS, as well as the Centers for Medicare and Medicaid
    Services 100 percent denominator file data. By linking these three
    databases, the study will help physicians make better decisions and
    improve healthcare for patients with coronary artery disease.
                National Cardiovascular Research Infrastructure (NCRI)
                        Grant
        The NHLBI also awarded a Grand Opportunity grant (Award Number
    1RC2HL101512-01) to Duke Clinical Research Institute (DCRI), with the
    ACC serving as a subcontractor, to develop a clinical investigator
    network based upon the data collection activities of ACC's National
    Cardiovascular Data Registries (NCDRr). These registries have
    previously been used to quantify outcomes and identify gaps in the
    delivery of quality cardiovascular patient care in the United States.
    The current grant will extend these existing systems by establishing a
    National Cardiovascular Research Infrastructure (NCRI) that will unify
    sites with a centralized clinical research network. NCRI will
    facilitate interoperable clinical research by enhancing site
    recruitment, training, performance, and accountability and will create
    a sustained improvement in the efficiency and quality of the
    interaction between the clinical research subject, the clinician
    investigator, the expert guidelines committee, and policymakers.
    Prospect Grants #RFA-HS-10-005: Building New Clinical Information for
            Comparative Effectiveness Research
                Valvular Heart Disease Registry Grant Application
        In February 2010, ACC and STS again joined forces to submit a grant
    application entitled ``ACCF-STS Database Development and Collaboration
    on the Comparative Effectiveness of Valvular Heart Disease.'' This
    application was in response to the above announcement from AHRQ. The
    DCRI Data Coordinating and Analysis Center collaborated on the
    development of this grant and, if awarded, would provide the clinical
    outcomes and analysis for the project. The purpose of this grant would
    be for ACCF and STS to take advantage of their existing registries to
    create and maintain a sustainable disease-based, multi-center registry
    for valvular heart disease (VHD), a robust, efficient system of
    longitudinal follow-up for registry patients, and to perform a direct
    comparison of initial clinical outcomes following different management
    strategies of patients with severe aortic stenosis.
                Infrastructure Development for the Comparative
                        Effectiveness of Atrial Fibrillation
        In partnership with the Heart Rhythm Society (HRS), ACC submitted a
    grant to AHRQ proposing to develop the electronic database
    infrastructure necessary to collect prospective data of patients with
    atrial fibrillation through use of ACC's NCDR. Once developed, new
    evidence comparing various interventions will be available by using
    this new NCDR registry database to better understand the procedures and
    improve healthcare for patients with atrial fibrillation, one of the
    most common arrhythmias in clinical practice. Such data will contain
    process, risk-adjusted outcomes, utilization, provider characteristics,
    and cost data spanning several years that has a potentially great
    benefit to society. Specifically, this study will permit comparative
    effectiveness research of the management of patients with atrial
    fibrillation, including comparisons across race, gender, and age. These
    comparisons will be more comprehensive than any currently available,
    and will be of inestimable benefit in provider decisionmaking and
    patient care in a variety of clinical situations.
    Enhanced Registries for Quality Improvement and Comparative
            Effectiveness (AHRQ #RFA-HS-10-020)
                Integrating Local EHR Data into the ACC NCDR Registry to
                        Improve Care (LEAN) Grant Application
        The aim of this grant application is to develop an informatics
    solution that captures and delivers real-time clinical patient
    information to multiple care settings. ACC is collaborating with Yale
    University School of Medicine, Christiana Care Center for Outcomes
    Research, Sisters of Mercy Health System, Saint Luke's Hospital of
    Kansas City-Mid America Heart Institute, and Duke University Medical
    Center on this important endeavor. The formation of the proposed
    infrastructure will not only drive quality improvement, but also
    facilitate comparative effectiveness research. This project aligns
    particularly well with the goals and purposes expressed nearly 2 years
    ago by the ACCF and the NCDR with the launch of the IC\3\ Registry
    (renamed the PINNACLE RegistryTM in the fall of 2009).
    PINNACLE was designed to improve the quality of outpatient
    cardiovascular care by reducing inappropriate variations in care, by
    eliminating gaps in care, and by improving care coordination for
    patients with cardiovascular disease. Realization of these objectives
    will rely on the existence of a strong, unified data collection
    infrastructure that will allow for retrieval across both inpatient and
    outpatient care settings, as well as provide quality improvement
    feedback.
                                     ______

          Prepared Statement of the Adult Congenial Heart Association

        The Adult Congenial Heart Association (ACHA) is pleased that the
    recently enacted ``Patient Protection and Affordable Care Act''
    includes provisions to enhance and expand the infrastructure to track
    the epidemiology of congenital heart disease (CHD) and to conduct and
    support research on causation, including genetic causes; long-term
    outcomes in individuals with congenital heart disease; diagnosis,
    treatment, and prevention; studies using longitudinal data and
    retrospective analysis to identify effective treatments and outcomes;
    and identifying barriers to life-long care for individuals with
    congenital heart disease. The Adult Congenital Heart Association, along
    with coalition partners Mended Little Hearts and Children's Heart
    Foundation, stand ready to work with the subcommittee and Members of
    Congress to advance these policies.
        CHD are the most common birth defect in the United States and are a
    leading cause of child mortality. The success of childhood cardiac
    intervention has created a new chronic disease--CHD. Those who receive
    successful intervention will need life-long special cardiac care and
    face high rates of heart failure, rhythm disorders, stroke, and sudden
    cardiac death. Thanks to the increase in survival, the CHD population
    is rising by 5 percent a year. There are about 800,000 children and 1
    million adults in the United States now living with CHD.
        Despite the prevalence and seriousness of the disease, data
    collection and research are limited. In 2004, the National Heart, Lung
    and Blood Institute (NHLBI) convened a working group on congenital
    heart disease, which recommended developing a research network to
    conduct clinical research and establishing a national database of
    patients.
        Federal funding support for CHD surveillance through CDC and
    research through NHLBI will help prevent premature death and disability
    in this rapidly growing and severely underserved population.
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists

        The American Congress of Obstetricians and Gynecologists,
    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 Department of Health and Human Services. Today,
    the United States lags behind other nations in healthy births, yet
    remains high in birth costs. ACOG's Making Obstetrics and Maternity
    Safer (MOMS) Initiative seeks to improve maternal outcomes through more
    research and better data, and we urge you to make this a top priority
    in fiscal year 2011.
        Research is critically needed to understand why our maternal and
    infant mortality rate remains comparatively high. Having better data
    collection methods and comprehensive maternal mortality reviews has
    shown maternal mortality rates in some States, such as California, to
    be higher than previously thought. States without these resources are
    likely underreporting maternal and infant deaths and complications from
    childbirth. Without accurate data, the full range of causes of these
    deaths remains unknown. Effective research based on comprehensive data
    is a key MOMS element to developing and implementing evidence-based
    interventions.
        Unfortunately, the MOMS Initiative is threatened by the sizeable
    cliff in research funding that will be created in fiscal year 2011 once
    the stimulus package ends this year. Building funding levels from the
    stimulus into the base for fiscal year 2011 appropriations will ensure
    the continuation of current research important to the MOMS Initiative,
    and ensure that future research necessary to improving maternal
    outcomes does not go unfunded.
        The President's budget for fiscal year 2011 takes a positive first
    step towards this goal, including a $1 billion increase for NIH, and
    ACOG requests the subcommittee build on these increases to maintain the
    momentum created by the stimulus. The NIH and many other HHS agencies
    are vital to carrying out the goals of the MOMS Initiative. Therefore,
    ACOG asks for a 13.5 percent increase for NIH to $35.2 billion, a 22.3
    percent increase for HRSA to $9.15 billion, a 35.9 percent increase for
    CDC to $8.8 billion, and a 53.9 percent increase for AHRQ to $611
    million.
        Research and programs in the following areas are vital to the MOMS
    Initiative:
    Maternal/Child Health Research at the NIH
        The Eunice Kennedy Shriver National Institute of Child Health and
    Human Development (NICHD) conducts the majority of women's health
    research. Despite the NIH's critical advancements, reduced funding
    levels have made it difficult for research to continue.
        ACOG supports a 12.5 percent increase in funds over fiscal year
    2010 to $1.495 billion for the NICHD. These funds will assist the
    following research areas critical to the MOMS Initiative:
                Reducing the Prevalence of Premature Births
        There is a known link between pre-term birth and infant mortality,
    and women of color are at increased risk for delivering pre-term. 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.
        ACOG supports the Surgeon General's effort to make the prevention
    of pre-term birth a national public health priority, and urges Congress
    to allocate $1 million to NICHD to create a Trans-disciplinary Research
    Center on Prematurity to help streamline efforts to reduce pre-term
    births.
                Obesity Research, Treatment, and Prevention
        Obese pregnant women are at higher risk for poor maternal and
    neonatal outcomes. Additional research and interventions are needed to
    address the increased risk for poor outcomes in obese women receiving
    infertility treatment, the increased incidence of birth defects and
    stillbirths in obese pregnant women, ways to optimize outcomes in obese
    women who become pregnant after bariatric surgery, and the increased
    future risk of childhood obesity in their offspring.
        ACOG is grateful to the NIH for making obesity a priority and
    initiating trans-disciplinary approaches to combat obesity. We also
    applaud First Lady Michelle Obama for naming childhood obesity a top
    priority. ACOG urges the NIH and the NICHD to make obesity in pregnant
    women a high priority, to improve the health of mother and child.
    Maternal/Child Health Programs at CDC
        CDC funds programs that are critical to providing resources to
    mothers and children in need. Where NIH conducts research to identify
    causes of pre-term birth, CDC funds programs that provide resources to
    mothers to help prevent pre-term birth, and help identify factors
    contributing to pre-term birth and poor maternal outcomes.
        ACOG supports a 35.9 percent increase in funds over fiscal year
    2010 to $8.8 billion to increase CDC's ability to bring prevention,
    treatment and interventions to more women and children in need, and to
    help enact some of the important provisions within healthcare reform.
    This funding will help the following programs important to the MOMS
    Initiative:
                Maternal Mortality Reviews, Division of Reproductive Health
        National data on maternal mortality is inconsistent and incomplete
    due to the lack of standardized reporting definitions and mechanisms.
    To capture the accurate number of maternal deaths and plan effective
    interventions, maternal mortality should be addressed through multiple,
    complementary strategies. ACOG recommends that CDC fund States in
    implementing maternal mortality reviews that would allow them to
    conduct regular reviews of all deaths within the State to identify
    causes, factors in the communities, and strategies to address the
    issues. Combined with adoption of the recommended birth and death
    certificates in all States and territories, CDC could then collect
    uniform data to calculate an accurate national maternal mortality rate.
    Results of maternal mortality reviews will inform research needed to
    identify evidence based interventions addressing causes and factors of
    maternal mortality and morbidity.
        ACOG urges Congress to provide $2.375 million to the Division of
    Reproductive Health to assist States in setting up maternal mortality
    reviews.
                Electronic Birth Records and Death Records, National Center
                        for Health Statistics (NCHS), National Vital
                        Statistics System (NVSS)
        NCHS is the Nation's principal health statistics agency; it
    collects, analyzes and reports on data critical to all aspects of our
    healthcare system. NCHS collects State data needed to monitor maternal
    and infant health, such as use of prenatal care, and smoking during
    pregnancy. This data allows investigators to monitor maternal and child
    health objectives, and develop efficient prevention and treatment
    strategies.
        Uniform consistent data from birth and death records is critical to
    conducting research and directing public programs to combat maternal
    and infant death. Only 75 percent of States and territories use the
    2003 recommended birth certificates and 65 percent have adopted the
    2003 recommended death certificate. Within the increased funding
    provided to NCHS in the President's budget, $8 million was included
    specifically for the National Vital Statistics System (NVSS) to support
    States and territories in implementing the 2003 birth certificate and
    modernizing their infrastructure to collect these data electronically
    to expand the scope and quality of data collected on a national basis.
    The President's budget provides NVSS $3 million to phase in the 2003
    death certificate and electronic death records in States and
    territories.
        ACOG urges Congress to allocate $11 million for States to modernize
    their birth and death records systems to the 2003 recommended
    guidelines, consistent with the President's budget.
                Safe Motherhood/Infant Health
        Two to three women a day die from delivery complications. The Safe
    Motherhood Program supports CDC's work with State health departments
    and other groups to identify and gather information on pregnancy-
    related deaths; collect and provide information about women's health
    and health behaviors before, during, and immediately after pregnancy;
    and expand the acceptance and use of findings and guidelines on
    preconception care into everyday practice and healthcare policy.
        Safe Motherhood also tracks infant morbidity and mortality
    associated with pre-term birth. ACOG is concerned with recent trends
    particularly among rates of late pre-term births. Increased funding is
    needed for CDC to improve national data systems to track pre-term birth
    rates and expand epidemiological research that focuses especially on
    the causes and prevention of preterm birth and births at 37-38 weeks
    gestation.
        ACOG urges Congress to include a 23.7 percent increase in funds to
    $55.4 million for Safe Motherhood, consistent with the President's
    budget.
    Maternal/Child Health Programs at HRSA
        HRSA delivers critical resources to communities to improve the
    health of mothers and children. ACOG urges a 22.3 percent increase in
    funds over fiscal year 2010 to $611 million to increase the scope of
    HRSA programs, ultimately bringing more resources to more mothers and
    children. This funding will help expand the following programs
    important to the MOMS Initiative:
                Fetal Infant Mortality Reviews, Healthy Start Program
        After decades of decline, the U.S. infant mortality rate is again
    on the rise and is particularly severe among minority and low-income
    women. The infant mortality rate among African American women has been
    increasing since 2001 and reached 14.2 deaths per 1,000 births in 2004.
    There also has been a startling rise in infant mortality in the South.
    Mississippi, for example, had an infant mortality rate of 11.4 in 2005
    compared to 9.6 the previous year.
        The Healthy Start Program through HRSA promotes community-based
    programs that focus on infant mortality and racial disparities in
    perinatal outcomes. These programs are encouraged to use the Fetal and
    Infant Mortality Review (FIMR) which brings together ob-gyn experts and
    local health departments to help solve problems related to infant
    mortality. Today more than 220 local programs in 42 States find FIMR a
    powerful tool to help solve infant mortality.
        ACOG urges Congress to include $.5 million for Healthy Start
    Programs to include FIMR.
                Maternal Child Health Block Grant (MCH)
        The MCH is the only Federal program that exclusively focuses on
    improving the health of mothers and children. State and territorial
    health agencies and their partners use MCH Block Grant funds to reduce
    infant mortality, deliver services to children and youth with special
    healthcare needs, support comprehensive prenatal and postnatal care,
    screen newborns for genetic and hereditary health conditions, deliver
    childhood immunizations, and prevent childhood injuries.
        ACOG urges Congress to increase funding for MCH $730 million, a
    10.3 percent increase over fiscal year 2010.
    Comparative Effectiveness Research on Maternal Disparities at AHRQ
        There are glaring disparities in maternal outcomes among different
    ethnic and racial groups, particularly related to pre-term birth and
    maternal and infant mortality rates among African American women. For
    that reason, disparities research is a major tenant of ACOG's MOMS
    Initiative. Comparative effectiveness research has the capacity to
    greatly improve pre-term birth rates and maternal and infant mortality
    rates by testing the efficacy of prevention and treatment interventions
    on different populations. As more comparative effectiveness research
    gets funded from the stimulus and healthcare reform bills, ACOG urges
    Congress to make disparities research into maternal outcomes a top
    priority.
        ACOG supports a 53.9 percent increase in funds for AHRQ to $611
    million, consistent with the President's budget.
        Again, we would like to thank the subcommittee for its continued
    support of programs to improve women's health, and we urge you to
    consider our MOMS Initiative in fiscal year 2011.
                                     ______

            Prepared Statement of the American College of Physicians

        Chairman Harkin and Ranking Member Cochran, thank you for allowing
    me to share the American College of Physicians' (ACP) views on the
    Department of Health and Human Services (HHS) budget for fiscal year
    2011.
        I am Joseph W. Stubbs, MD, FACP, President of the ACP. I have also
    had the privilege of serving adult patients for the past 27 years as a
    full-time internist and geriatrician in a nine-person primary care
    group practice in Albany, Georgia. Every day, I see where the rubber of
    health policy meets the road of real patient lives. In my practice, we
    have more than 50 employees, and I have seen the ratio of physician to
    staff grow from 1:3 to 1:6 in the last 10 years. Healthcare in the
    United States is facing an unprecedented challenge of affordability and
    sustainability. I am pleased to be able to represent ACP.
        ACP represents 129,000 internal medicine physicians, residents, and
    medical students. ACP is also the Nation's largest medical specialty
    society and its second largest physician membership organization.
        ACP is pleased to urge full funding for the following proven
    programs that currently receive appropriations from the subcommittee:
      --Title VII, section 747, Primary Care Training and Enhancement, at
            no less than $125 million;
      --National Health Service Corps, $414,095,394, in addition to the
            $290 million in enhanced funding through the Community Health
            Fund; and
      --Agency for Healthcare Research and Quality, $611 million.
        In addition to fully funding the existing programs noted above, ACP
    is pleased to support the following new programs, as created in the
    Patient Protection and Affordable Care Act (PPACA), with the
    stipulation that they should be fully funded:
      --Title VII, section 747A, Teaching Health Centers, $50 million;
      --Primary Care Training Extension Program, $120 million;
      --National Health Care Workforce Commission;
      --State healthcare workforce development grants; and
      --State demonstration programs to evaluate alternatives to current
            medical tort litigation, $50 million.
        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 adult primary care specialties steadily declines. With
    passage of the PPACA, we expect the demand for primary care services to
    increase with the addition of 32 million Americans receiving access to
    health insurance, once the law is fully implemented.
        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 that more than 100 studies show primary care is
    associated with better outcomes and lower costs of care (http://
    www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf).
        Many regions of the country 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. A 2008 study published in Health
    Affairs projects a shortage of 35,000 to 40,000 or more primary care
    physicians for adults by 2025 (Colwill JM, Cultice JM, Kruse RL. Will
    generalist physician supply meet demands of an increasing and aging
    population? Health Affairs (Millwood). 2008 May-Jun;27(3):w232-41. Epub
    2008 Apr 29). With an aging and growing population, family physicians'
    and general internists' workloads are expected to increase by 29
    percent between 2005 and 2025. To help alleviate the shortage of
    primary care physicians, we believe sufficient funding should be
    provided for title VII programs and the National Health Service Corps.
        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 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, and are critical to help institutions and programs
    respond to the current and emerging challenges of ensuring all
    Americans have access to appropriate and timely health services.
        Within the title VII program, while we applaud the President's
    request for $54 million for the section 747, Training in Primary Care
    Medicine and Dentistry, with passage of the PPACA and the
    reauthorization of the section 747, Primary Care Training and
    Enhancement, we urge the subcommittee to fund the program at $177.6
    million, which is double the amount of funding the program received in
    fiscal year 2005, the high watermark for this program. We urge the
    subcommittee to not designate a percentage of the funding to a specific
    primary care disciple, as has been done in previous years. The
    reauthorization of the section 747 program calls for capacity building
    in the fields of general internal medicine, general pediatrics, and
    family medicine, as well as eliminates the rateable reduction language
    which has diverted over two-thirds of the funding in this program to
    one primary care discipline. The section 747 program is the only source
    of Federal training dollars available for general internal medicine,
    general pediatrics, and family medicine. For example, general
    internists, who have long been at the frontline of patient care, have
    benefited from title VII training models that promoted
    interdisciplinary training that helped prepare them to work with other
    health professionals, such as physician assistants, patient educators
    and psychologists.
        ACP strongly supports the creation of the title VII, section 749A,
    Teaching Health Centers Development Grants, as established in the
    PPACA, which would provide grants and Graduate Medical Education
    funding for Teaching Health Centers to train primary care physicians in
    community based settings. Developing residency programs within
    community-based ambulatory primary care settings, with the appropriate
    infrastructure investment, will help strengthen the primary care
    workforce. Residents in primary care training programs need increased
    exposure to the ambulatory care setting, a practice environment that
    demonstrates that satisfaction can be gained from providing ongoing,
    continuous care to patients. The evidence suggests that residents who
    spend increased time in outpatient settings opposed to the hospital
    deliver a higher quality of care and maintained a higher degree of
    satisfaction from their work. ACP strongly urges the subcommittee to
    fully fund this program at its fiscal year 2011 authorized level of $50
    million.
        ACP recommends an appropriation of $414,095,394 for the National
    Health Service Corps (NHSC), the amount authorized for fiscal year 2011
    under the PPACA. This is in addition to the $290 million in enhanced
    funding the HHS Secretary has been given the authority to provide to
    the NHSC through the Community Health Care Fund in fiscal year 2011, as
    authorized under the PPACA. The increase in funds must be sustained to
    help address the health professionals' workforce shortage and growing
    maldistribution.
        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. 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.
        At a field strength of 4,760 in fiscal year 2009, the NHSC fell
    more than 24,000 practitioners short of fulfilling the need for primary
    care, dental, and mental health practitioners in Health Professions
    Shortage Areas (HPSA), as estimated by HRSA. The NHSC estimates that
    nearly 50 million Americans currently live in a HPSA and that 27,000
    primary care professionals are needed to adequately serve the people
    living in a HPSA. 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. 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 Primary Care Extension Program, a new program created by the
    PPACA under title III of the Public Health Service Act, would help to
    educate and provide technical assistance to primary care providers
    including general internists currently in practice, about evidence-
    based therapies, preventive medicine, health promotion, chronic disease
    management, and mental health. This much-needed assistance will
    strengthen primary care practices caring for newly insured individuals
    and an aging population with multiple chronic conditions. ACP
    encourages the subcommittee to fund this program at its fiscal year
    2011 authorized level of $120 million.
        We encourage the subcommittee to fully fund the necessary amounts
    for the National Health Care Workforce Commission, as created by the
    passage of the PPACA. The Commission is authorized to review current
    and projected healthcare workforce supply and demand and make
    recommendations to Congress and the administration regarding national
    healthcare workforce priorities, goals, and polices. ACP believes the
    Nation needs sound research methodologies embedded in its workforce
    policy to determine the Nation's current and future needs for the
    appropriate number of physicians by specialty and geographic areas; the
    work of the Commission is imperative to ensure Congress is creating the
    best policies for our Nation's needs.
        The PPACA also establishes a competitive healthcare workforce
    development grant program for the purpose of enabling State
    partnerships to complete comprehensive planning and to carry out
    activities leading to coherent and comprehensive healthcare workforce
    development strategies at the State and local levels. We urge the
    subcommittee to fully fund the necessary amounts as needed, for both
    planning and implementation grants, given that our States are an
    essential link in sustaining our Nation's health.
        The Agency for Healthcare Research and Quality (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 endorses
    the President's fiscal year 2011 budget request of $611 million. This
    amount will allow AHRQ to continue its critical healthcare safety,
    quality, and efficiency initiatives; strengthen the infrastructure of
    the research field; re-ignite innovation and discovery; develop the
    next generation of scientific pioneers; and ultimately, help transform
    health and healthcare.
        ACP is supportive of ARHQ's investigator-initiated research
    program, a critically important element of our Nation's healthcare
    research effort. The funding stream provides for many clinical
    innovations, innovations that improve patient outcomes, facilitates the
    translation of research into clinical practice and disease management
    strategies, and addresses 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.
        The PPACA allows the HHS Secretary to establish State demonstration
    programs to evaluate alternatives to current medical tort litigation,
    such as certificate of merit programs, which require a finding that a
    suit has merit before it can proceed to trial, and health courts, which
    would have cases heard by a panel of medical experts rather than a lay
    jury. ACP believes that reform of medical liability system is
    essential, and this program is a step in that direction. ACP strongly
    urges the subcommittee to fully fund the program at its authorized
    level of $50 million immediately, allowing States the opportunity to
    build upon the work already being done under the October 2009 Funding
    Opportunity Announcement released by AHRQ, entitled ``Medical Liability
    Reform and Patient Safety Planning Grants.''

                                   CONCLUSION

        Mr. Chairman and Ranking Member Cochran, I appreciate the
    opportunity to offer testimony on the importance of HHS budget for
    fiscal year 2011.
        ACP is keenly aware of the fiscal pressures facing the subcommittee
    today, but strongly believes the United States must invest in these
    programs in order to achieve a high performance healthcare system and
    build capacity in our public health system. ACP greatly appreciates the
    support of the subcommittee on these issues and looks forward to
    working with Congress as you begin to work on the fiscal year 2011
    appropriations process.
                                     ______

       Prepared Statement of the American College of Preventive Medicine

    Recommendation
        The American College of Preventive Medicine (ACPM) urges the Labor,
    Health and Human Services, Education, and Related Agencies
    Appropriations Subcommittee to reaffirm its support for training
    preventive medicine physicians and other public health professionals by
    providing $5 million in fiscal year 2011 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 $600 million be appropriated in fiscal year
    2011 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''. 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 professionals.
    ---------------------------------------------------------------------------
        \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 public 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\
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
        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. Yet, the skills needed to effectively prepare for and
    respond to bioterrorism and other public health threats--epidemiologic
    surveillance, disease prevention and containment, understanding and
    management of the health systems--are at the heart of preventive
    medicine training and public health practice. Preventive medicine
    training produces the public health leaders needed to effectively
    respond to today's threats to the public's health. A recent article on
    public health leadership trends showed that health department directors
    who were not physicians had difficulty handling serious outbreaks and
    other medical emergencies.\9\
    ---------------------------------------------------------------------------
        \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.
        \9\ Kahn, LH. A Prescription for Change: The Need for Qualified
    Physician Leadership in Public Health. Health Affairs 2003; 22:241-8.
    ---------------------------------------------------------------------------
    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.\10\
    ---------------------------------------------------------------------------
        \10\ 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.\11\
    ---------------------------------------------------------------------------
        \11\ 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.\12\
    ---------------------------------------------------------------------------
        \12\ 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\
        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.\13\ 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 or who do not have
    specific interests in areas for which limited stipends are available
    (such as research in cancer prevention).
    ---------------------------------------------------------------------------
        \13\ 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.
    ---------------------------------------------------------------------------
        The Health Resources and Services Administration (HRSA)--as
    authorized in title VII of the Public Health Service Act--is a critical
    funding source for several preventive medicine residency programs, as
    it represents the largest Federal funding source for these programs.
    HRSA funding ($2.3 million in 2010) currently supports only physicians
    in preventive medicine training programs. An increase of $2.7 million
    will allow HRSA to support up to 25 new preventive medicine residents.
        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.
      --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.
    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 guided 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
                                     (ACRT)

        The Association for Clinical Research Training (ACRT), the
    Association for Patient-Oriented Research (APOR), the Clinical Research
    Forum (CR Forum), and the Society for Clinical and Translational
    Science (SCTS) represent a coalition of professional organizations
    dedicated to improving the health of the public through increased
    clinical and translational research, and clinical research training.
    United by the shared priorities of the clinical and translational
    research community, ACRT, APOR, CR Forum, and SCTS advocate for
    increased clinical and translational research at the National
    Institutes of Health (NIH), the Agency for Healthcare Research and
    Quality (AHRQ), and other Federal science agencies.
        On behalf of ACRT, APOR, CR Forum, and SCTS, I would like to thank
    the Subcommittee for their continued support of clinical and
    translational research, and clinical research training. The creation of
    the Patient-Centered Outcomes Research Institute in recent healthcare
    reform legislation will provide a much-needed and greatly appreciated
    boost to comparative effectiveness research (CER) at the Federal level.
    As outlined by NIH Director Dr. Francis Collins in his five priorities
    for NIH, the translation of basic science to clinical treatment is an
    integral component of modern biomedical research, and a necessity to
    developing the treatments and cures of tomorrow.
        Today, I would like to address a number of issues that cut to the
    heart of the clinical and translational research community's
    priorities, including the Clinical and Translational Science Awards
    program (CTSA) at NIH, career development for clinical researchers, and
    support for CER at the Federal level.
        As our Nation's investment in biomedical research expands to
    provide more accurate and efficient treatments for patients, we must
    continue to focus on the translation of basic science to clinical
    research. The CTSA program at NIH is quickly becoming an invaluable
    resource in this area, but full funding is needed if we are to truly
    take advantage of the CTSA infrastructure.
    Fully Funding and Support for the CTSA Program at NIH
        With its establishment in 2006, the CTSA program at NIH began to
    address the need for increased focus on translational research, or
    research that bridges the gap between basic science discoveries and the
    bedside. Originally envisioned as a consortium of 60 academic
    institutions, the CTSA program currently funds 46 academic medical
    research institutions nationwide, and is set to expand to the full 60
    by 2012. The CTSAs have an explicit goal of improving healthcare in the
    United States by transforming the biomedical research enterprise to
    become more effectively translational. Specifically, the CTSA program
    hopes to (1) improve the way biomedical research is conducted across
    the country; (2) reduce the time it takes for laboratory discoveries to
    become treatments for patients; (3) engage communities in clinical
    research efforts; (4) increase training and development in the next
    generation of clinical and translational researchers; and (5)
    accelerate T1 translational science.
        Although the promise of the CTSA program is recognized both
    nationally and internationally, it has suffered from a lack of proper
    funding along with NIH, and the National Center for Research Resources
    (NCRR). In 2006, 16 initial CTSAs were funded, followed by an
    additional 12 in 2007 and 14 in 2008. Level-funding at NIH curtailed
    the growth of the CTSAs, preventing recipient institutions from fully
    implementing their programs and causing them to drastically alter their
    budgets after research had already begun. If budgets continue to
    decline, the CTSAs risk jeopardizing not only new research but also the
    research begun by first, second, and third generation CTSAs.
    Professional judgment determined full funding to be at a level of $700
    million.
        We recognize the difficult economic situation our country is
    currently experiencing, and greatly appreciate the commitment to
    healthcare Congress has demonstrated through stimulus funding, the
    fiscal year 2010 appropriations process, and most recently through
    healthcare reform. The CTSAs are currently funding 46 academic research
    institutions nationwide at a level of $474 million, with the goal of
    full implementation by 2012. In order to reach full implementation of
    60 CTSAs by 2012, and to realize the promise of the CTSAs in
    transforming biomedical research to improve its impact on health, it is
    imperative that the CTSA program receive funding at the level of $700
    million in fiscal year 2011. Without full funding, more CTSAs will be
    expected to operate with fewer resources, curtailing their
    transformative promise.
        A major part of the CTSA program's promise lies in its synergy with
    all of NIH's Institutes and Centers (ICs), and the acceleration and
    facilitation of the ICs' impact. The translation of laboratory research
    to clinical treatment directly benefits patients suffering from complex
    diseases and all fields of medicine. The CTSA program has created
    improved translational research capacity and processes from which all
    NIH's ICs stand to benefit. The development of a formal NIH-wide plan
    to link all ICs to the CTSA program would efficiently capitalize on NIH
    and NCRR's investment in clinical and translational science.
        It is our recommendation that the subcommittee support full
    implementation of the CTSA program by providing $700 million in fiscal
    year 2011, and we ask that the subcommittee support the development of
    a formal NIH-wide plan to integrate the CTSAs to all of NIH's
    Institutes and Centers.
    Continuing Support for Research Training and Career Development
            Programs Through the K Awards
        The future of our Nation's biomedical research enterprise relies
    heavily on the maintenance and continued recruitment of promising young
    investigators. Clinical investigators have long been referred to as an
    ``endangered species'', as financial barriers push medical students
    away from research. This trend must be arrested if we are to continue
    our pursuits of better treatments and cures for patients.
        The K Awards at NIH and AHRQ provide much-needed support for the
    career development of young investigators. As clinical and
    translational medicine takes on increasing importance, there is a great
    need to grow these programs, not reduce them. Career development grants
    are crucial to the recruitment of promising young investigators, as
    well as to the continuing education of established investigators.
    Reduced commitment to the K-12, K-23, K-24, and K-30 awards would have
    a devastating impact on our pool of highly trained clinical
    researchers. Even with the full implementation of the CTSA program, it
    will be critical for institutions without CTSAs to retain their K-30
    Clinical Research Curriculum Awards, as the K-30s remain a highly cost-
    effective method of ensuring quality clinical research training. ACRT,
    APOR, CRF, and SCTS strongly support the ongoing commitment to clinical
    research training through K Awards at NIH and AHRQ.
        We ask the subcommittee to continue their support for clinical
    research training and career development through the K Awards at NIH
    and AHRQ, in order to promote and encourage investigators working to
    transform biomedical science.
    Continuing Support for CER
        Comparative effectiveness research or ``CER'' emerged at the
    forefront of the healthcare reform debate, capturing the interest of
    lawmakers and the American people. CER is the evaluation of the impact
    of different options that are available for treating a given medical
    condition for a particular set of patients. This broad definition can
    include medications, behavioral therapies, and medical devices among
    other interventions, and is an important facet of evidence-based
    medicine. On behalf of ACRT, APOR, CR Forum, and SCTS, I would like to
    thank the Senate for the creation of the Patient-Centered Outcomes
    Research Institute in the Patient Protection and Affordable Care Act,
    as well as the $1.1 billion included for CER at NIH and AHRQ in the
    American Recovery and Reinvestment Act (ARRA). Both AHRQ and NIH have
    long histories of supporting CER, and the standards for research
    instituted by agencies like NIH and AHRQ serve as models for best
    practices worldwide. Not only are these agencies experienced in CER,
    they are universally recognized as impartial and honest brokers of
    information.
        We are pleased that Congress recognizes the importance of these
    activities and believe that the peer review processes and
    infrastructure in place at NIH and AHRQ ensure the highest quality CER.
    We believe that collaboration between the Patient-Centered Outcomes
    Research Institute, NIH, and AHRQ will motivate all Federal CER
    efforts. In addition to support for the CTSA program at NIH, we
    encourage the Subcommittee to provide continued support for Patient-
    Centered Health Research at AHRQ.
        Thank you for the opportunity to present the views and
    recommendations of the clinical research training community. On behalf
    of ACRT, APOR, CR Forum, and SCTS, I would be happy to be of assistance
    as the appropriations process moves forward.
                                     ______

         Prepared Statement of the American College of Sports Medicine

        On behalf of the American College of Sports Medicine (ACSM), I am
    pleased to offer this written testimony to the Senate Appropriations
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies for inclusion in the official Committee record. I will
    focus my comments on the importance of programs within the Department
    of Health and Human Services (HHS), the Department of Education, and
    programs recently authorized in the Patient Protection and Affordable
    Care Act (Public Law 111-148) that serve as a means to educate about or
    provide services that enhance healthy lifestyles for all Americans.
    Within these programs, ACSM is strongly supportive of the inclusion of
    provisions that enhance access to information about physical activity
    and exercise as a mechanism for improving health and reducing chronic
    diseases or health disparities.
        ACSM is a 35,000-member organization that applies knowledge,
    training, and dedication in sports medicine and exercise science to
    promote healthier lifestyles for people around the globe. ACSM members
    are dedicated to improving public health through a spectrum that ranges
    from basic research to translating that research into effective
    practice. ACSM members include leading scientists, physicians,
    educators, public health experts, clinical exercise physiologists,
    health and fitness professionals, physical therapists, and more.
        The Nation's focus on physical activity and exercise as a means to
    improve health and prevent disease has recently been garnering
    increased attention. However, expanded and sustained Federal support is
    necessary to fully leverage the health benefits that have been shown to
    result from physical activity and exercise. Additional funding is
    needed to expand basic and translational research to ensure that the
    most up-to-date and effective guidance is disseminated and that
    programs are developed with the goals of keeping Americans strong and
    healthy and reducing the levels of chronic diseases such as heart
    disease, diabetes, obesity, stroke, osteoporosis, and depression.
        In particular, scientific and medical research conducted at the
    National Institutes of Health (NIH) will be instrumental in building on
    current efforts to improve the Nation's health and reduce diseases and
    health disparities. ACSM appreciates the subcommittee's past support
    for NIH and encourages the subcommittee to maintain its commitment by
    allocating a total discretionary budget of $32.239 billion, which is
    equal to the President's fiscal year 2011 budget request for NIH. ACSM
    also encourages the subcommittee to direct a portion of this increased
    funding toward institutes and programs that focus on prevention and
    wellness. The combination would allow NIH to fund a record number of
    research grants, including those that will help us to understand what
    is needed to ensure Americans live healthier lifestyles.
        In addition, summarized below are recommendations for fiscal year
    2011 funding for programs within HHS, the Department of Education, and
    new programs recently authorized through the Patient Protection and
    Affordable Care Act (Public Law 111-148) to help ensure that the
    necessary mechanisms are provided to improve health, eliminate
    disparities, and reduce diseases among all Americans.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

        The agencies within HHS include programs that support ACSM's goals.
    ACSM urges the subcommittee's support for the following HHS programs:
        Community Health Centers.--ACSM appreciates the subcommittee's
    support for the Health Centers program within the Health Resources and
    Services Administration (HRSA). The Health Centers program provides
    access to comprehensive primary healthcare, including supportive
    services such as transportation and education for individuals and
    families in high-need communities. ACSM urges the Committee to
    appropriate at least the President's fiscal year 2011 request of $2.5
    billion for the program, an increase of $290 million above the fiscal
    year 2010 enacted level and to direct a portion of this funding to
    allow new and existing centers to expand to include services and
    information that highlight the health benefits of physical activity and
    exercise.
        Centers for Disease Control and Prevention.--ACSM supports the
    increases proposed in the President's fiscal year 2011 budget request
    for programs within the Centers for Disease Control and Prevention
    (CDC), including: Chronic Disease Prevention, Health Promotion and
    Genomics, a total of $937 million; Public Health Research, a total of
    $31 million; and Preventive Health and Health Services Block Grant, a
    total of $102 million. ACSM urges the Committee to direct a portion of
    the funding within these programs to physical activity and exercise
    programs and research.

                   PATIENT PROTECTION AND AFFORDABLE CARE ACT

        ACSM urges the subcommittee to fund the following programs
    authorized in the Patient Protection and Affordable Care Act (Public
    Law 111-148), which deal with prevention of chronic disease and
    improving public health:
        Prevention and Public Health Fund.--This fund would be administered
    by the Secretary of HHS and would increase funding for programs
    authorized by the Public Health Service Act for prevention, wellness,
    and public health activities. ACSM urges the Committee to use its
    authority to transfer money from the fund to existing or new programs
    authorized by the Public Health Service Act that have a particular
    focus on physical activity and exercise, including the Community
    Transformation grant program.
        U.S. Preventive Services Task Force/Community Preventive Services
    Task Force.--These task forces will coordinate with the Advisory
    Committee on Immunization Practices, and will comprise experts to
    review scientific evidence related to effectiveness, appropriateness,
    and cost-effectiveness of clinical preventive services for the purpose
    of developing recommendations to be widely distributed to and utilized
    by the public. ACSM urges the Committee to appropriate the necessary
    funding to establish these task forces, in order to help ensure that
    the best practices in health and wellness, including physical activity
    and exercise guidelines and recommendations, are being promoted.
        Education and Outreach Campaign.--This campaign would be developed
    by a public-private partnership with the aim of raising public
    awareness of health improvement across the life span. ACSM urges the
    Committee to appropriate funding to allow for successful development
    and implementation of the campaign.

                            DEPARTMENT OF EDUCATION

        ACSM urges the subcommittee to support the following program at the
    Department of Education:
        Carol M. White Physical Education Program/Successful, Safe, and
    Healthy Students.--ACSM supports programming within the Department of
    Education that focuses on developing healthy lifestyles for students
    and the Nation's youth population. In the President's fiscal year 2011
    budget request, the Carol M. White Physical Education Program was
    proposed for consolidation into an overarching Successful, Safe, and
    Healthy Students program, of which one goal is improving students'
    physical health and well-being through the use of, or access to,
    comprehensive services that improve student physical activity and
    fitness. ACSM urges the Committee to provide increased funding for the
    Carole M. White Physical Education Program or direct a significant
    portion of the funding provided to the Successful, Safe, and Healthy
    Students program to focus on physical activity, exercise, and the
    development of healthy lifestyles for youth.
        I appreciated the opportunity to submit these recommendations and
    hope the Committee will consider them while developing appropriations
    for fiscal year 2011.
                                     ______

            Prepared Statement of the American Diabetes Association

        Thank you for the opportunity to provide this testimony to the
    Senate Labor, Health and Human Services, and Education, and Related
    Agencies Subcommittee. I am pleased to have the opportunity to submit
    testimony on behalf of the American Diabetes Association. As someone
    who has lived with diabetes for more than 30 years, I am proud to be a
    representative of the 81 million American adults and children living
    with diabetes or pre-diabetes.
        Every minute, three more people are diagnosed with the disease.
    While nearly 24 million Americans have diabetes today, that number is
    expected to grow to 44 million in the next 25 years if present trends
    continue. Every 24 hours, 230 people with diabetes will undergo an
    amputation, 120 people will enter end-stage kidney disease programs,
    and 55 people will go blind from diabetes. Each and every day diabetes
    will cost our country over a half a billion dollars, yet, it is but a
    fraction of the costs that lie ahead unless we take action immediately
    to stop the march of this epidemic.
        Thanks to you and your colleagues, Congress has consistently funded
    vital Department of Health and Human Services programs to help reduce
    the overwhelming costs of diabetes. However, if we are to cure and
    prevent diabetes, there is much more to accomplish. Therefore, the
    Association urges the Senate Labor, Health and Human Services, and
    Education, and Related Agencies Subcommittee to invest in research and
    prevention proportionate to the magnitude of the burden diabetes has on
    our country and, by doing so, to change the future of diabetes in
    America.
        As the Nation's leading nonprofit health organization providing
    diabetes research, information and advocacy, the Association believes
    Federal funding for diabetes prevention and research is critical, not
    only for the 24 million American adults and children (nearly 8 percent
    of the population) who currently have diabetes, but for the 57 million
    more with pre-diabetes. Of the 24 million, 6 million are unaware they
    have diabetes. Together, this means 25 percent of the U.S. population
    either has, or is at risk for developing, this serious disease. Federal
    funding for diabetes prevention and research efforts is critical to
    reversing this epidemic.
        Diabetes is a chronic condition that impairs the body's ability to
    use food for energy. The hormone insulin, which is made in the
    pancreas, helps the body change food into energy. In people with
    diabetes, either the pancreas does not create insulin, which is type 1
    diabetes, or the body does not create enough insulin and/or cells are
    resistant to insulin, which is type 2 diabetes. If left untreated,
    diabetes results in too much glucose in the blood stream. The majority
    of diabetes cases, 90 to 95 percent, are type 2, while type 1 diabetes
    accounts for 5 to 10 percent of diagnosed cases. The complications of
    diabetes are widespread and serious. In those with pre-diabetes, blood
    glucose levels are higher than normal and taking action to reduce their
    risk of developing diabetes is essential.
        The Centers for Disease Control and Prevention (CDC) has identified
    diabetes as a disabling, deadly epidemic that is on the rise. Between
    1990 and 2001, the prevalence of diabetes increased by 60 percent.
    According to the CDC, 1 in 3 children born in the year 2000 is likely
    to develop the disease in their lifetime if current trends continue.
    This number is even greater among minority populations, where nearly 1
    in 2 children will develop diabetes.
        Additionally, type 2 diabetes, traditionally seen in older
    patients, is beginning to reach a younger population, due in part to
    the surge in childhood obesity. Approximately 1 in every 500 children
    and adolescents has Type 1 diabetes, and an alarming 2 million
    adolescents (or 1 in 6 overweight adolescents) aged 12-19 have pre-
    diabetes. The impact diabetes has on individuals and the healthcare
    system is enormous and continues to grow at a shocking rate. Diabetes
    is a leading cause of kidney disease, adult-onset blindness and lower
    limb amputations as well as a significant cause of heart disease and
    stroke. Since 1987, the death rate due to diabetes has increased by 45
    percent. In that same period, death rates for heart disease, stroke,
    and cancer have dropped.
        In addition to the physical toll, diabetes also attacks our
    pocketbooks. A recent study by the Lewin Group found when factoring in
    the additional costs of undiagnosed diabetes, pre-diabetes, and
    gestational diabetes, the total cost of diabetes and related conditions
    in the United States in 2007 was $218 billion ($18 billion for
    undiagnosed diabetes; $25 billion for pre-diabetes; $623 million for
    gestational diabetes). That year, medical expenditures due to diabetes
    totaled $116 billion, including $27 billion for diabetes care, $58
    billion for chronic diabetes-related complications, and $31 billion for
    excess general medical costs. Indirect costs resulting from increased
    absenteeism, reduced productivity, disease-related unemployment
    disability and loss of productive capacity due to early mortality
    totaled $58 billion. This is an increase of 32 percent since 2002.
    Thus, in just 5 years, the cost of diabetes increased by $42 billion,
    or $8 billion per year. In fact, approximately 1 out of every 5
    healthcare dollars is spent caring for someone with diagnosed diabetes,
    while 1 in 10 healthcare dollars is attributed to diabetes.
    Additionally, one-third of Medicare expenses are associated with
    treating diabetes and its complications.
        Despite these numbers, there is hope. A greater Federal investment
    in diabetes research at the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH), and prevention, surveillance, control, and research work
    currently being done at the Division of Diabetes Translation (DDT) at
    the CDC is crucial for finding a cure and improving the lives of those
    living with, or at risk for, diabetes. Additionally, the National
    Diabetes Prevention Program (NDPP), a new program authorized through
    the Patient Protection and Affordable Care Act (Public Law 111-148,
    section 399V-3), is poised to cut dramatically the number of new
    diabetes cases in high-risk individuals. In this vein, for fiscal year
    2011, the American Diabetes Association is requesting:
      --$2.209 billion for the NIDDK, an increase of $252 million over the
            fiscal year 2010 level. This additional funding will act to
            offset years of flat funding and inflation that caused cutbacks
            to promising research. It will also demonstrate Congress's
            commitment to science and research.
      --$86 million for the CDC's DDT, which represents a total increase of
            $20 million for the DDT's critical prevention, surveillance and
            control programs. Expanded investment in the DDT will produce
            much larger savings in reduced acute, chronic, and emergency
            care spending.
        Additionally, we are also requesting your support of $80 million
    for the implementation of the NDPP through the Prevention and Public
    Health Fund created in Public Law 111-148.
    NIH's National Institute of Diabetes and Digestive and Kidney Diseases
            (NIDDK)
        One of the 27 Institutes housed at the NIH, NIDDK is poised to make
    major discoveries that could prevent diabetes, better treat its
    complications, and--ultimately--find a cure. Researchers at the NIH are
    working on a variety of projects that represent hope for the millions
    of individuals with both type 1 and type 2 diabetes. The list of
    advances in treatment and prevention is long, but it is important to
    understand much more can be achieved for people with diabetes with an
    increased investment in scientific research at the NIDDK.
        Researchers have already learned a great deal about the biology of
    diabetes, and they now understand much more about the loss of islet
    cell function, which can affect the body's ability to regulate blood
    glucose levels. These discoveries have led directly to islet cell
    transplants and ongoing work to extend the life of transplanted cells.
    Thanks to research at the NIDDK, people with diabetes now manage their
    disease with a variety of insulin formulations and regimens far
    superior to those used in decades past. The result is the ability to
    live healthier lives with diabetes. Because of these advances, my
    hemoglobin A1C, which provides a snapshot of an individual's blood
    glucose, went from 12.9 percent to 5.9 percent. This is a dramatic
    development for me and proof of the importance of NIDDK's work.
        Recent discoveries at the NIDDK include the ability to predict type
    1 diabetes risk, new drug therapies for type 2 diabetes, and the
    discovery of genetic markers that explain the increased burden of
    kidney disease among African Americans. The NIDDK funded the Diabetes
    Prevention Program, a multicenter clinical research trial that found
    modest weight loss through dietary changes and increased physical
    activity could prevent or delay the onset of type 2 diabetes by 58
    percent.
        While great strides have been made in diabetes research, there are
    many unanswered questions about the disease that merit further study.
    Towards that end, the NIDDK, in its role as the convener of the
    Diabetes Mellitus Coordinating Committee, a panel of key HHS agencies,
    including the Food and Drug Administration and the CDC, and other
    Federal partners such as the Department of Veterans Affairs, has
    developed a Diabetes Research Strategic Plan, to be finalized later
    this year, which outlines diabetes research needs.
        The plan identifies a number of areas for additional research.
    These include study into the intersection of genetic and environmental
    risk factors for diabetes in people of color in order to reduce the
    prevalence of the disease and its complications; identification of the
    key genetic factors that predispose or protect individuals against
    diabetes complications; and, study of the natural history of type 1
    diabetes in order to foster the design of preventive therapy.
    Additional fiscal year 2011 funding would allow the NIDDK to support
    additional research in order to build upon past successes, improve
    prevention and treatment, and close in on a cure.
    CDC's Division of Diabetes Translation (DDT)
        The CDC's DDT works to eliminate the preventable burden of diabetes
    through proven educational programs, best practice guidelines and
    applied research. Funds appropriated to the DDT focus on developing and
    maintaining State-based Diabetes Prevention and Control Programs
    (DPCPs); supporting the National Diabetes Education Program (NDEP);
    defining the diabetes burden through the use of public health
    surveillance; and translating research findings into clinical and
    public health practice. Our request of an additional $20 million will
    allow these critical programs at the DDT to reach more at risk
    Americans and help to prevent or delay this destructive disease.
        The DDT's most important efforts are based within the DPCPs in all
    50 States, the District of Columbia, and 8 other territories and are
    cornerstones of the Division's work. DPCPs work to not only reduce the
    incredible burden of diabetes, but to make certain the people they
    serve are fully aware of the disease and those with or at risk of
    developing diabetes are receiving the highest quality of care possible.
    Because they are community based, DPCPs are highly adaptable and
    capable of reaching those at greatest risk in a given area. DPCPs
    provide a vital infrastructure to coordinate diabetes prevention and
    control efforts, however, a severe lack of funding leaves DPCPs unable
    to reach all of those who could benefit from their work.
        The Division also recognizes the role that education and awareness
    plays in the fight against diabetes. With this in mind, the DDT
    implements the NDEP in coordination with the NIDDK. The NDEP develops
    and disseminates information on the prevention and control of diabetes
    that serve as the guiding principles to improve the treatment and
    outcomes for people with diabetes and to prevent or delay the onset of
    diabetes. Another vital component of the DDT's efforts is the National
    Diabetes Surveillance System, which provides comprehensive diabetes
    data at the national, State, and local levels so analysts may better
    track the epidemic, and ensure the most effective use of taxpayer
    dollars.
        The DDT also identifies important research findings, including the
    results of clinical trials and scientific studies, in order to pinpoint
    the public health implications of the research. These findings are
    applied in healthcare systems and within local communities. Areas of
    translational research include access to quality care for diabetes;
    cost-effectiveness of diabetes prevention and control activities;
    effectiveness of health practices to address risk factors for diabetes;
    and demonstration of primary prevention of type 2 diabetes. One example
    of a highly successful translational effort by the DDT is the Diabetes
    Prevention Program Initiative (DPPI), a structured lifestyle
    intervention modeled after the NIDDK's Diabetes Prevention Program
    (DPP) clinical research study. The DPPI is proving group lifestyle
    intervention can lower diabetes risk while being delivered in a cost
    effective way in a community setting, thus increasing the likelihood of
    improved outcomes for individuals at risk of developing the disease.
        While the DDT has played an invaluable and instrumental role in
    fighting the diabetes epidemic, the reach of the Division could be
    significantly broader with additional fiscal year 2011 funding. With an
    additional $20 million, the DDT will be able to expand the reach of
    DPCPs in every State and territory. Given the dramatic decreases in
    funding for State and local health departments, supporting the work of
    the DPCPs to provide prevention and control guidelines and technical
    assistance to health officials in local communities is more critical
    than ever to ensure access to affordable and high-quality diabetes care
    and services.
        Increased funding for the DDT will also allow the Division to build
    upon its work in reducing health disparities through vital programs
    such as the Native Diabetes Wellness Program, furthering the
    development of effective health promotion activities and messages
    tailored to American Indian/Native Alaskan communities. Additional
    resources will enable the DDT to expand its translational research
    studies that will lead to improved public health interventions. An
    excellent example of this work is the Search for Diabetes in Youth
    study; a collaboration between the DDT and the NIDDK designed to
    further clarify the impact of type 2 diabetes in youth so prevention
    activities aimed at young people can be improved.
    The National Diabetes Prevention Program (NDPP)
        Further studies of the DPP have shown this groundbreaking
    intervention can be replicated in community settings for a cost of less
    than $300 per participant. With this in mind, the NDPP was authorized
    by the Patient Protection and Affordable Care Act of 2010 (Public Law
    111-148). This new program will provide funding to the CDC to expand
    such evidence-based programs across the country. The Association
    acknowledges your leadership in the implementation of Public Law 111-
    148, specifically the Prevention and Public Health Fund (section 4002),
    which provided $15 billion in mandatory funding over the next 10 years
    for public health, wellness and prevention programs. We respectfully
    ask the subcommittee to support $80 million from the Fund for the NDPP.
        The NDPP meets the goals of the Fund, which seeks to make a
    national investment in prevention and public health programs, both to
    improve the health of Americans and to rein in healthcare costs. The
    Urban Institute reported our country could save as much as $190 billion
    over 10 years by bringing the NDPP to scale. Implementation of the NDPP
    would allow the CDC to expand the reach of evidence-based community
    programs to identify, refer and provide those at high risk for diabetes
    with cost-effective interventions.

                                   CONCLUSION

        As you consider the fiscal year 2011 appropriation for the NIDDK
    and the DDT, we ask that you consider diabetes is an epidemic growing
    at an astonishing rate. If left unaddressed diabetes will overwhelm the
    healthcare system with tragic consequences. To change this future we
    need to increase our commitment to research and prevention in a way
    that reflects the burden diabetes poses both for us and for our
    children.
        Increasing NIDDK funding to $2.209 billion for next year opens the
    door to research opportunities that will both improve patient outcomes
    and reduce the economic cost of diabetes. Through the CDC's important
    programs at the DDT, we have the chance to drastically reduce the
    number of people with diabetes. Given the astounding costs of diabetes,
    the request of $86 million for DDT is a modest investment in our
    future. Further, $80 million from the Prevention and Public Health Fund
    for the implementation of the NDPP will not only improve the health of
    millions of Americans who are at high risk for diabetes, but it will
    also save healthcare costs in the long term.
        Our fight against diabetes must be significantly expanded. Your
    continued leadership in combating this growing epidemic is essential in
    stemming the epidemic. Thank you for your commitment to the diabetes
    community and for the opportunity to submit this testimony. The
    Association is prepared to answer any questions you might have on these
    important issues.
                                     ______

        Prepared Statement of the American Dental Education Association

        The American Dental Education Association (ADEA) is pleased to
    offer its recommendations for fiscal year 2011 appropriations for
    dental education and research.
        The ADEA represents all 60 dental schools in the United States, in
    addition to more than 700 dental residency training programs and nearly
    600 allied dental programs, as well as more than 12,000 faculty who
    educate and train the nearly 50,000 students and residents attending
    these institutions. It is at these academic dental institutions that
    future practitioners and researchers gain their knowledge, where the
    majority of dental research is conducted, and where significant dental
    care is provided. ADEA member institutions serve as dental homes for a
    broad array of racially and ethnically diverse patients, many who are
    uninsured, underinsured, or reliant on public programs such as Medicaid
    and the Children's Health Insurance Program for their healthcare.
        ADEA's requests build upon funding from the American Economic
    Recovery and Reinvestment Act (ARRA) and the Labor, Health and Human
    Services, and Education, and Related Agencies fiscal year 2010
    appropriations. The Department of Health and Human Services has several
    oral health programs that address the various aspects needed to improve
    oral healthcare in America. These programs build and sustain State oral
    health departments, fund proven public health programs to prevent oral
    disease, target research to eradicate dental disease, and work to
    develop an adequate workforce of dentists with advanced training to
    serve children, the aged and those suffering from specific diseases
    like AIDS.
        Our budget recommendations include the following:
      --Dental Education.--The Title VII Health Professions Education and
            Training Programs and Diversity and Student Aid Programs,
            administered by the Health Resources and Services
            Administration (HRSA);
      --Oral Health Research.--The National Institutes of Health (NIH) and
            the National Institute of Dental and Craniofacial Research
            (NIDCR); and
      --Access to Care.--The Ryan White CARE Act HIV/AIDS Dental
            Reimbursement Program and the Community-Based Dental
            Partnerships Program; the Dental Health Improvement Act; the
            Oral Health Program at the Centers for Disease Control and
            Prevention (CDC); and the National Health Service Corps (NHSC).
        Specifically, the ADEA respectfully urges the subcommittee to
    provide $30 million for section 5303 of (Public Law 111-148) for the
    continuation and enhancement of dental training programs. The following
    programs help to address the Nation's oral healthcare needs:

                                DENTAL EDUCATION

    $16 Million for General Dentistry and Pediatric Dentistry Residency
            Training in the Title VII Health Professions Programs
        The Title VII General and Pediatric Dentistry Programs are critical
    to building the primary care dental workforce. Support for these
    programs is essential to expanding existing or establishing new general
    dentistry and pediatric dentistry residency programs, which have shown
    to be effective in increasing access to dental care for vulnerable
    populations, including patients with developmental disabilities,
    children, and geriatric patients. These primary care dental residency
    programs generally include outpatient and inpatient care and afford
    residents an excellent opportunity to learn and practice in all phases
    of primary care dentistry, including trauma and emergency care, and
    comprehensive ambulatory dental care for adults and children.
    $118 Million for Diversity and Student Aid
                $33 Million for Centers of Excellence
                $49 Million for Scholarships for Disadvantaged Students
                $35 Million for Health Careers Opportunity Program
                $1.3 Million for Faculty Loan Repayment Program
        The Title VII Diversity and Student Aid programs play a critical
    role in helping to diversify the health profession's student body and
    thereby the healthcare workforce. Blacks, Hispanics, and American
    Indians currently represent more than 25 percent of the U.S.
    population. By the year 2050, nearly 1 in 5 Americans (19 percent) will
    be an immigrant, compared with 1 in 8 (12 percent) in 2005. Despite
    these population trends, minorities are underrepresented in the U.S.
    healthcare workforce. This is no less true of dentistry, where they
    comprise less than 5 percent of dentists and about 9 percent of dental
    faculty. For the last several years, these programs have not enjoyed an
    adequate level of funding to sustain the progress that is necessary to
    meet the challenges of an increasingly diverse U.S. population.

                              ORAL HEALTH RESEARCH

    $35 Billion for the NIH, Including $463 Million for the NIDCR
        Discoveries stemming from dental research have reduced the burden
    of oral diseases, led to better oral health for tens of millions of
    Americans, and uncovered important associations between oral and
    systemic health. Dental researchers are poised to make new
    breakthroughs that can result in dramatic progress in medicine and
    health, such as repairing natural form and function to faces destroyed
    by disease, accident, or war injuries; diagnosing systemic disease from
    saliva instead of blood samples; and deciphering the complex
    interactions and causes of oral health disparities involving social,
    economic, cultural, environmental, racial, ethnic, and biological
    factors. Dental research is the underpinning of the profession of
    dentistry. With grants from NIDCR, dental researchers in academic
    dental institutions have built a base of scientific and clinical
    knowledge that has been used to enhance the quality of the Nation's
    oral health and overall health.
        Dental scientists also are putting science to work for the benefit
    of the healthcare system through translational research, comparative
    effectiveness research, health information technology, health research
    economics, and further research on health disparities. NIDCR continues
    to make disparities a priority by renewing five disparities centers for
    2008-2015: Boston University Henry M. Goldman School of Dental
    Medicine, the University of California San Francisco School of
    Dentistry, the University of Colorado Denver School of Dental Medicine,
    the University of Florida College of Dentistry, and the University of
    Washington School of Dentistry.
        The latest NHANES data that provided a full dental examination,
    1999-2004, show that dental caries in young children has actually
    increased, particularly in those populations covered by SCHIP and
    Medicaid. The June 2009 IOM Study on Comparative Effectiveness Research
    (CER) included two oral health topics in the top 100 national
    priorities for CER.
        NIDCR funded four ARRA Challenge Grants on CER. Investments in
    dental research will produce inventions that make corporations more
    competitive in the global economy and benefit everyone with new
    businesses and jobs. Investments in dental research will produce
    inventions that make corporations more competitive in the global
    economy and benefit everyone with new businesses and jobs. It is
    important to note that NIH disproportionately creates higher-paying
    employment opportunities that require a higher level of technical
    sophistication in construction, staffing, and supporting laboratories.
    The average wage associated with jobs created through NIH grants and
    contracts was $52,000 in 2007.

                             ACCESS TO DENTAL CARE

    $19 Million for the Dental Reimbursement Program and the Community-
            Based Dental Partnerships Program, part F of the Ryan White
            HIV/AIDS Treatment and Modernization Act
        Patients with compromised immune systems are more prone to oral
    infections like periodontal disease and tooth decay. By providing
    reimbursement to dental schools and schools of dental hygiene, the
    Dental Reimbursement Program provides access to quality dental care for
    people living with HIV/AIDS while simultaneously providing educational
    and training opportunities to dental residents, dental students, and
    dental hygiene students who deliver the care. The Dental Reimbursement
    Program is a cost-effective Federal/institutional partnership that
    provides partial reimbursement to academic dental institutions for
    costs incurred in providing dental care to people living with HIV/AIDS.
    Particularly important to this program is the fact that Congress
    designated dental care as a ``core medical service'' when it
    reauthorized the Ryan White program in 2006.
        The Community-Based Dental Partnership Program fosters partnerships
    between dental schools and communities lacking academic dental
    institutions to ensure access to dental care for HIV/AIDS patients
    living in those areas.
    $20 Million for the Dental Health Improvement Act (DHIA)
        This program supports the development of innovative dental
    workforce programs specific to States' dental workforce needs and
    increases access to dental care for underserved populations. In fiscal
    year 2006, Congress provided first-time DHIA funding of $2 million to
    assist States in developing innovative dental workforce programs. The
    inaugural grant cycle, held in fiscal year 2006, yielded 36
    applications from States. Eighteen States were awarded grants ranging
    from $67,865 to $124,080. Grants are being used to support a variety of
    initiatives including, but not limited to, loan repayment programs to
    recruit culturally and linguistically competent dentists to work in
    underserved areas with underserved populations including the
    developmentally disabled; rotating residents and students in rural
    areas; recruiting dental school faculty; training pediatricians and
    family medicine physicians to provide oral health services (screening
    exams, risk assessments, fluoride varnish application, parental
    counseling, and referral of high-risk patients to dentists); and
    supporting teledentistry.
    $33 Million for the Oral Health Programs at the Centers for Disease
            Control and Prevention (CDC)
        The CDC Oral Health Program expands the coverage of effective
    prevention programs. The program increases the basic capacity of State
    oral health programs to accurately assess the needs of the State,
    organize and evaluate prevention programs, develop coalitions, address
    oral health in State health plans, and effectively allocate resources
    to the programs. CDC's funding and technical assistance to States is
    essential to help oral health programs build capacity. Increasing the
    funding will help to ensure that all States that apply may be awarded
    an oral health grant.
    $414 Million for the NHSC
        The NHSC scholarship and loan repayment program provides awards to
    healthcare professionals, including dentists and dental hygienists who
    agree to work in underserved communities for a minimum of 2 years.
    Participants must work in a Health Professional Shortage Area (HPSA),
    and dentists and dental hygienists work in Dental Health Professional
    Shortage Areas (Dental HPSAs). According to the HRSA there are 4,230
    Dental HPSAs with 49 million people living in them. It would take 9,642
    practitioners to meet their need for dental providers (a population to
    practitioner ratio of 3,000:1). The dedicated clinicians of the NHSC
    provide quality care to millions of people who would otherwise lack
    adequate access to health services.
        The ADEA is grateful to the subcommittee for considering our fiscal
    year 2011 budget requests for Federal agencies and programs that
    sustain and enhance dental education, oral health research, and access
    to care. A continuing Federal commitment is needed to help meet the
    challenges oral diseases pose to the Nation's most vulnerable citizens,
    including children. Also critical is the development of a partnership
    between the Federal Government and dental education programs to
    implement a national oral health plan that guarantees access to dental
    care for everyone, ensures continued dental health research, and
    eliminates disparities and workforce shortages.
                                     ______

                 Prepared Statement of the Arthritis Foundation

        The Arthritis Foundation greatly appreciates the opportunity to
    submit testimony in support of increased funding for arthritis
    prevention at the Centers for Disease Control and Prevention (CDC);
    additional investment in arthritis research at the National Institutes
    of Health (NIH); and funding for the Health Resources and Services
    Administration (HRSA) to commence a loan repayment program for
    pediatric specialists.
        Arthritis is a term used to describe more than 100 different
    conditions that affect joints as well as other parts of the body.
    Arthritis is one of the most prevalent chronic health problems and the
    most common cause of disability in the United States. Forty-six million
    people (1 in 5 adults) and almost 300,000 children live with the pain
    of arthritis every day. The medical and societal impact of arthritis in
    the United States is staggering at $128 billion, including $81 billion
    in direct costs for physician visits and surgical interventions and $47
    billion in indirect costs for missed work days. Counter to public
    perception, two-thirds of the people with doctor-diagnosed arthritis
    are under the age of 65.
        By the year 2030, an estimated 67 million or 25 percent of the
    projected adult population will have arthritis. Furthermore, arthritis
    limits the ability of people to effectively manage other chronic
    diseases. More than 57 percent of adults with heart disease and more
    than 52 percent of adults with diabetes also have arthritis. The
    Arthritis Foundation strongly believes that in order to prevent or
    delay arthritis from disabling people and diminishing their quality of
    life that a significant investment in prevention and intervention
    strategies is essential. Research shows that the pain and disability of
    arthritis can be decreased through early diagnosis and appropriate
    management, including evidence based self-management activities such as
    weight control and physical activity. The Arthritis Foundation's Self-
    Help Program, a group education program, has been proven to reduce
    arthritis pain by 20 percent and physician visits by 40 percent. These
    interventions are recognized by the CDC to reduce the pain of arthritis
    and importantly reduce healthcare expenditures through a reduction in
    physician visits.
    CDC
        During the past year, the CDC has partnered with the Arthritis
    Foundation and more than 50 organizations to create a National Public
    Health Agenda for Osteoarthritis. The Agenda states the need to
    increase availability of evidence-based intervention strategies;
    increase public health attention for prevention and disease management;
    and increase research to better understand disease risk factors and
    other effective disease management strategies.
        With CDC funding, 12 State health departments in partnership with
    other State organizations have successfully increased public awareness
    of the burden of arthritis and increased the availability of four main
    interventions. First, self-management education (as described above) is
    proven to improve the quality of life and healthcare for people with
    arthritis and should be expanded to people with symptomatic arthritis.
    Second, physical activity is the best medicine to fight arthritis pain.
    The promotion of low-impact aerobic physical activity and muscle
    strengthening exercises for weight loss and to provide joint support is
    key. Losing just 1 pound of weight reduces 4 pounds of pressure off
    each knee. Third, preventing joint injuries through existing policies
    and interventions which have been shown to reduce arthritis-related
    joint injuries. Finally, promoting weight management and healthy
    nutrition will facilitate the prevention and treatment of arthritis.
    Now, is the time to make a significant investment to sustain and
    improve the reach of these proven interventions.
        Currently, the CDC's arthritis program receives $13 million in
    annual funding and about half of that amount is distributed via
    competitive grant to 12 States. An additional investment of $10 million
    would fund 12-14 new States and enable evidence-based prevention
    programs to reach many more Americans through innovative delivery
    approaches. The Arthritis Foundation strongly recommends that Congress
    invest an additional $10 million (total of $23 million) in the CDC's
    arthritis program in fiscal year 2011 to expand proven prevention and
    treatment strategies and fund up to 14 new States.
    NIH/National Institute of Arthritis and Musculoskeletal and Skin
            Diseases (NIAMS)
        While new treatment options are available which greatly improve the
    quality of life for people living with arthritis, the ultimate goal is
    to find a cure. The Arthritis Foundation firmly believes research holds
    the key to tomorrow's advances and provides hope for a future free from
    arthritis pain. As the largest nonprofit contributor to arthritis
    research, the Arthritis Foundation fills a vital role in the big
    picture of arthritis research. Our research program complements
    Government and industry-based arthritis research by focusing on
    training new investigators and pursuing innovative strategies for
    preventing, controlling, and curing arthritis. By supporting
    researchers in the early stages of their careers, the Arthritis
    Foundation makes important initial discoveries possible that lead to
    ultimate breakthrough results.
        The mission of NIAMS is to support research into the causes,
    treatment, and prevention of arthritis and musculoskeletal and skin
    diseases, the training of basic and clinical scientists to carry out
    this research, and the dissemination of information on research
    progress in these diseases. Research opportunities at NIAMS are being
    curtailed due to the stagnating and in some cases declining numbers of
    new grants being awarded for specific diseases. The training of new
    investigators has unnecessarily slowed down and contributed to a crisis
    in the research community where new investigators have begun to leave
    biomedical research careers in pursuit of other more successful
    endeavors.
        The Arthritis Foundation is dedicated to finding a cure for
    arthritis. However, the investment in NIH research is absolutely
    crucial to realize this dream. With continued and increased investment
    in research, the Arthritis Foundation believes a cure is on the
    horizon. To support research that will lead to improved treatments and
    a potential cure for arthritis, the Arthritis Foundation urges Congress
    to provide $603.8 million, a 12 percent increase, for the NIH/NIAMS.
    HRSA
        Juvenile arthritis is the leading cause of acquired disability in
    children and is the sixth most common childhood disease. Sustaining the
    field of pediatric rheumatology is essential to the care of the almost
    300,000 children under the age of 18 living with a form of juvenile
    arthritis. Children who are diagnosed with juvenile arthritis will live
    with this chronic and potentially disabling disease for their entire
    life. Therefore, it is imperative that children are diagnosed quickly
    and start treatment before significant irreversible joint damage is
    done. However, it is a challenge to first find a pediatric
    rheumatologist, as nine States do not have a single one, and then to
    have a timely appointment as many States have only one or two to see
    thousands of patients. Pediatric rheumatology is one of the smallest
    pediatric subspecialties with less than 200 pediatric rheumatologists
    actively practicing in the United States. A report to Congress in 2007
    stated there was a 75 percent shortage of pediatric rheumatologists and
    recommended loan repayment program to help address the workforce issue.
        The recent passage of the Patient Protection and Affordable Care
    Act authorizes HRSA to commence a loan repayment program for pediatric
    specialists and authorizes Congress to appropriate $30 million for this
    program. A percentage of this funding should be allocated for pediatric
    rheumatology. The Arthritis Foundation strongly recommends funding this
    program immediately at the $30 million level to help increase the
    pediatric rheumatology workforce.
        The Arthritis Foundation appreciates the opportunity to submit our
    recommendations to Congress on behalf of the 46 million people with
    arthritis. The mission of the Arthritis Foundation is the prevention,
    control, and cure of arthritis. The Arthritis Foundation urges Congress
    to focus Federal investment through a $23 million appropriation for
    arthritis prevention at CDC; a $30 million appropriation to help
    control juvenile arthritis; and a 12 percent increase toward a cure in
    arthritis research at the NIH. Each part of the equation-prevention,
    control, and cure-are an essential part to a future world free of
    arthritis pain and disability.
                                     ______

              Prepared Statement of the American Heart Association

        Over the past 50 years, significant progress has been made in the
    battle against cardiovascular disease (CVD) and stroke. The improved
    diagnosis and treatment has been remarkable--as has the survival rate.
    According to the National Institutes of Health (NIH), 1.6 million lives
    have been saved since the 1960s that otherwise would have been lost to
    CVD. Americans can expect to live on average 4 years longer due to the
    reduction in heart-related deaths.
        However, one startling fact remains. Heart disease and stroke are
    still respectively the No. 1 and No. 3 killers of men and women in the
    United States. Nearly 2,300 Americans die of CVD each day--one death
    every 38 seconds. CVD is a leading cause of disability and will cost
    our Nation an estimated $503 billion in medical expenses and lost
    productivity this year.
        An estimated 81 million American adults now suffer from heart
    disease, stroke, and other forms of CVD. Risk factors such as obesity
    and diabetes are increasing. At the age of 40, lifetime risk for CVD is
    2 in 3 for men and more than 1 in 2 for women.
        In the face of these staggering statistics, heart disease and
    stroke research, treatment and prevention programs remain woefully
    underfunded and overall funding for the NIH is too volatile to have the
    continuity of effort needed for the major breakthroughs that will
    redefine diseases, spur prevention and promote best care.
        CVD is the No. 1 killer in each State and many preventable and
    treatable risk factors continue to rise. Yet, the Centers for Disease
    Control and Prevention (CDC) invests on average only 16 cents per-
    person a year on heart disease and stroke prevention. Specifically, CDC
    still provides basic implementation awards to only 14 States for its
    Heart Disease and Stroke Prevention Program and only 20 States are
    funded for WISEWOMAN--a heart disease and stroke screening and
    prevention program proven to be effective in reaching uninsured and
    under-insured low-income women ages 40 to 64 with a high prevalence of
    risk factors for these diseases.
        Where you live could also affect if you survive a very deadly form
    of heart disease--sudden cardiac arrest (SCA). Only 10 States received
    funding in fiscal year 2009 for 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 applauds the Administration and
    Congress for providing hope to the 1 in 3 adults in the United States
    who live with the consequences of CVD through the enactment of the
    American Recovery and Reinvestment Act (ARRA).
        The $10 billion in funding for NIH and the $650 million for
    Communities Putting Prevention to Work Program are wise and prudent
    investments that have provided a much needed boost to improve our
    Nation's physical and fiscal health. Yet, these funds denote a one-time
    infusion of resources. Stable and sustained funding is imperative in
    fiscal year 2011 to advance heart disease and stroke research,
    prevention and treatment.

         FUNDING RECOMMENDATIONS: INVESTING IN THE HEALTH OF OUR NATION

        Heart disease and stroke risk factors continue to rise, yet
    promising research opportunities to stem this tide go unfunded.
    Americans still die from CVD, while proven prevention programs and
    techniques beg for implementation. Clearly, now is the time to
    capitalize on the momentum achieved under ARRA to enhance research,
    prevention and treatment of America's No. 1 and most costly killer. If
    Congress fails to build on this progress, Americans will pay more in
    the future in lives lost and higher healthcare costs. Our
    recommendations below address these issues in a comprehensive and
    fiscally responsible manner.
    Capitalize on ARRA Investment for the National Institutes of Health
            (NIH)
        NIH research has revolutionized patient care and holds the key to
    finding new ways to prevent, treat and even cure CVD, resulting in
    longer, healthier lives and reduced healthcare costs. NIH invests
    resources in every State and in 90 percent of congressional districts.
    Each NIH grant generates on average 7 jobs.
        The American Heart Association Advocates.--We advocate for a fiscal
    year 2011 appropriation of $35.2 billion for NIH--a $4.2 billion
    increase more than fiscal year 2010, to capitalize on the momentum
    achieved under the ARRA investment to save lives, advance better
    health, spur our economy and spark innovation. NIH-supported research
    prevents and cures disease, generates economic growth and preserves the
    U.S. role as the world leader in pharmaceuticals and biotechnology.
    Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise
            Investment
        Death rates for coronary heart disease fell 36 percent and nearly
    34 percent for stroke from 1996-2006. These declines are directly
    related to NIH heart and stroke research, with scientists on the verge
    of exciting discoveries that could lead to new treatments and even
    cures. Landmark NIH research has shown that surgery and stenting are
    both safe and effective in preventing stroke. It has demonstrated that
    over-zealous blood pressure lowering and combination lipid drugs do not
    cut cardiovascular disease in adult diabetics more so than standard
    evidence-based care; nor does postmenopausal hormone therapy avert
    heart disease or stroke. And it has defined the genetic basis of risky
    responses to vital blood-thinners.
        In addition to saving lives, NIH-funded 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
    savings of $1.27 billion. But, in the face of such solid returns on
    investments and other successes, NIH still invests a meager 4 percent
    of its budget on heart research, and a mere 1 percent on stroke
    research.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute (NHLBI)
        Despite progress and promising research opportunities, there is no
    cure yet for CVD. As our population ages, the demand will increase for
    more and better ways to allow Americans to live healthy and productive
    lives despite CVD. Stable and sustained funding is needed to allow
    NHLBI to build on ARRA investments that provided grants to use genetics
    to identify and treat those at greatest risk from heart disease; hasten
    drug development to treat high cholesterol and high blood pressure; and
    create tailored strategies to treat, slow or prevent heart failure.
    Other important studies include an analysis of whether maintaining a
    lower blood pressure than currently recommended further reduces risk of
    heart disease, stroke, and cognitive decline. This information is
    critically important to ideally manage the burden of heart disease and
    stroke. Continued needed funding will allow for aggressive
    implementation of other initiatives in both the NHLBI general and
    cardiovascular strategic plans.
    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 6.4 million survivors face
    severe physical and mental disabilities, emotional distress and huge
    costs--a projected $74 billion in medical expenses and lost
    productivity in 2010.
        Stable and sustained funding is required for NINDS to capitalize on
    ARRA investments to prevent stroke, protect the brain from damage and
    enhance rehabilitation. This includes: (1) initiatives to determine
    whether MRI brain imaging can assist in selecting stroke victims who
    could benefit from the clot busting drug tPA beyond the 3-hour
    treatment window; (2) assessing chemical compounds that might shield
    brain cells during a stroke; and (3) advance stroke rehabilitation by
    studying whether the brain can be helped to ``rewire'' itself.
        Continued needed funding will also allow for assertive
    implementation of the NINDS Stroke Progress Review Group Report--a
    long-term, stroke research strategic plan. A variety of research
    initiatives have been undertaken, but more resources are needed to
    fully implement the plan. The fiscal year 2010 estimate for NINDS
    stroke research is less than half of the expected need.
        The American Heart Association Advocates: AHA supports an fiscal
    year 2011 appropriation of $3.514 billion for the NHLBI; and $1.857
    billion for the NINDS. These funding levels represent comparable
    increases to the Association's overall recommended percentage increase
    for the NIH.
    Increase Funding for the Centers for Disease Control and Prevention
            (CDC)
        Prevention is the best way to protect the health of all 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. Currently, CDC invests on
    average only 16 cents per-person each year on heart disease and stroke
    prevention.
        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 still funds only 14 States to implement programs in
    healthcare, worksite and community settings to: (1) reduce high blood
    pressure and elevated cholesterol; (2) improve emergency response and
    quality care; and (3) end treatment disparities. Another 27 States
    receive funds for capacity building (planning). However, 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. Nine States
    receive no prevention resources at all.
        This CDC division also administers the WISEWOMAN program that
    screens uninsured and under-insured low-income women ages 40 to 64 in
    20 States for heart disease and stroke risk. They receive counseling,
    education, referral and follow-up as needed. From 2000 to mid-2008,
    WISEWOMAN reached more than 84,000 low-income women, provided more than
    210,000 lifestyle interventions, and identified 7,647 new cases of high
    blood pressure, 7,928 new cases of high cholesterol, and 1,140 new
    cases of diabetes. Among those participants who were re-screened 1 year
    later, average blood pressure and cholesterol levels had decreased
    considerably.
        The American Heart Association Advocates: AHA joins with the CDC
    Coalition in support of an appropriation of $8.8 billion for CDC core
    programs, including increases for the Heart Disease and Stroke
    Prevention Program and WISEWOMAN. Within the total for CDC, AHA
    recommends $76.221 million for the Heart Disease and Stroke Prevention
    Program, allowing CDC to: (1) add the nine unfunded States; (2) elevate
    more States 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 National, State
    and local heart disease and stroke surveillance; and (6) provide
    additional assistance for prevention research and program evaluation.
    AHA also advocates $37 million to expand WISEWOMAN to additional States
    and screen more eligible women in funded States. And, we join the
    Friends of the NCHS in recommending $162 million for the National
    Center for Health Statistics.
    Restore Funding for Rural and Community Access to Emergency Devices
            (AED) Program
        About 92 percent of SCA victims die outside of a hospital. However,
    prompt CPR and defibrillation, with an automated external defibrillator
    (AED), can more than double their chances of survival. Communities with
    comprehensive AED programs have achieved survival rates of about 40
    percent. HRSA's Rural and Community AED Program provides grants to
    States to buy AEDs, train lay rescuers and first responders in their
    use and place AEDs where SCA is likely to occur. During year one, 6,400
    AEDs were bought, and placed and 38,800 people were trained. Due to
    budget cuts, only 10 States received funds for this life-saving program
    in fiscal year 2009.
        The American Heart Association Advocates: For fiscal year 2011, AHA
    advocates restoring HRSA's 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 on
    outcomes, comparative effectiveness and appropriateness of
    pharmaceuticals, devices and healthcare services for diseases, such as
    heart disease, stroke, and high blood pressure. Also, AHRQ's health
    information technology (HIT) plan is helping bring healthcare into the
    21st century through more than $300 million invested in over 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 is a key component to healthcare
    reform.
        The American Heart Association Advocates.--AHA joins Friends of
    AHRQ in advocating for $611 million for AHRQ to preserve its vital
    initiatives, boost the research infrastructure, reignite innovation,
    nurture the next generation of scientists and help reinvent health and
    healthcare.
        Cardiovascular disease continues to inflict a deadly, disabling and
    costly toll on Americans. But, our recommended funding increases for
    NIH, CDC, and HRSA outlined above will save lives and cut rising
    healthcare costs. The American Heart Association urges Congress to
    seriously consider our recommendations during the fiscal year 2011
    appropriations process. They represent a wise investment for our Nation
    and the health and well-being of this and future generations.
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium

                        DEPARTMENT OF EDUCATION PROGRAMS

    Higher Education Act Programs
        Strengthening Developing Institutions.--Section 316 of Higher
    Education Act (HEA) 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 $36 million to support these two vital
    programs.
        TRIO Programs.--Retention and support services are vital to
    achieving the administration's goal of having the highest percentage of
    college graduates globally by 2020. The President's fiscal year 2011
    budget request includes level funding for TRIO programs, which if
    ultimately enacted, will result in a decrease in the current level of
    program services. In addition to increasing Pell Grants, it is
    imperative that Congress bolster TRIO programs such as Student Support
    Services and Upward Bound so that low-income students are given the
    support necessary to persist in and, ultimately, complete their
    postsecondary courses of study. The TCUs support an increase in fiscal
    year 2011 TRIO programs and technical assistance funding.
        Pell Grants.--TCUs urge the subcommittee to fund the Pell Grant
    program at the highest possible level.
    Perkins Career and Technical Education Programs
        Section 117 of the Carl D. Perkins Vocational and Technical
    Education Act provides funding for the operating budgets for the
    Nation's two tribally controlled vocational institutions: United Tribes
    Technical College in Bismarck, North Dakota, and Navajo Technical
    College in Crownpoint, New Mexico. AIHEC requests $10 million for the
    two tribal colleges that are funded under this section. 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 funding 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.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES PROGRAM

    Tribal Colleges and Universities 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 a minimum of $5 million be designated
    for the TCU-Head Start Partnership program, to ensure the continuation
    of current programs and the resources needed to expand participation to
    include 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, 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 more than 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 2011 appropriations requests for tcus
    Higher Education Act
        The Higher Education Act Amendments 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 the 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 $36 million in fiscal year 2011 for HEA title III-A section
    316, an increase of $5.8 million more than fiscal year 2010, and to
    direct the Department to reserve a portion of the funds, as authorized,
    to award several competitive construction grants. 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, as well as their
    substandard facilities and infrastructure issues.
        Retention and support services are vital to achieving the
    administration's goal of having the highest percentage of college
    graduates globally by 2020. The TRIO-Student Support Services program
    was created out of recognition that college access was not enough to
    ensure advancement and that multiple factors worked to prevent the
    successful completion of higher education for many low-income and
    first-generation students and students with disabilities. Therefore, in
    addition to increasing Pell Grants, it is critical that Congress also
    bolster student assistance programs such as Student Support Services so
    that low-income students have the support necessary to allow them to
    persist in and, ultimately, complete their postsecondary courses of
    study.
        The importance of Pell Grants to TCU students cannot be overstated.
    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. 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 Career and Technical
    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 $10 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 State and local education agencies,
    Indian tribes, agencies, and TCUs. 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 funds appropriated for the Adult Education State Grants
    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.

    DEPARTMENT OF HEALTH AND HUMAN SERVICES/ADMINISTRATION FOR CHILDREN AND
                              FAMILIES/HEAD START

        Tribal Colleges and Universities (TCU) 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 TCUs request that the subcommittee direct the
    Head Start Bureau to designate a minimum of $5 million, of the more
    than $8.2 billion included in the President's fiscal year 2011 budget
    request for programs under the Head Start Act, for the TCU-Head Start
    Partnership program, to ensure that this critical program can be
    expanded so that all TCUs have the opportunity to participate in the
    TCU-Head Start Partnership program to benefit their respective tribal
    communities.

                                   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 2011 appropriations needs and recommendations.
                                     ______

    Prepared Statement of the American Institute for Medical and Biological
                                  Engineering

        Mr. Chairman and members of the subcommittee: The American
    Institute for Medical and Biological Engineering (AIMBE) appreciates
    the opportunity to submit testimony to advocate for funding for
    research within the National Institutes of Health (NIH) broadly, and
    specifically research funding within the National Institute for
    Biomedical Imaging and Bioengineering (NIBIB). NIH and NIBIB provide
    avenues for research funding that are vital to the Nation's efforts to
    support medical and biological engineering (MBE) innovation. AIMBE
    represents 50,000 individuals and organizations throughout the United
    States, including major healthcare companies, academic research
    institutions and the top 2 percent of engineers, scientists and
    clinicians whose discoveries and innovations have touched the health of
    many Americans. While today's testimony focuses on the impact MBE has
    on improving the health and well being of Americans, it is important to
    note that MBE can also have a positive impact on many of the other
    important issues facing us today; ranging from improvements to the
    environment by finding green-energy solutions, to solving problems
    relating to hunger, disease prevention, diagnosis and treatment of
    disease; to economic growth spurred by the innovation of new health
    products.
        AIM BE was founded in 1991 to establish a clear and comprehensive
    identity for the field of medical and biological engineering--which
    applies principles of engineering science and practice to imagine,
    create, and perfect the medical and biological technologies that are
    used to improve the health and quality of life of Americans and people
    across the world. AIMBE's vision is to ensure MBE innovations continue
    to develop for the benefit of humanity.
        AIMBE applauds the past support of this subcommittee to provide
    funding to NIH, and is particularly pleased to see the strong
    investment in NIH provided by the American Recovery and Reinvestment
    Act. However, we believe more stable, adequate and reliable funding is
    necessary to ultimately ensure America remains competitive and
    continues to develop innovations that improve human health. We
    therefore support NIBIB at the level of $332.4 million for fiscal year
    2011. This increase in funding will support important work which is
    highly translatable or applicable research into products that are life-
    saving, and life enhancing. NIBIB is the only Institute at the NIH with
    the specific purpose of supporting and conducting biomedical
    engineering research, which impacts all sectors of health across many
    disease states. Research conducted within NIBIB is on the cutting edge
    of biomedical engineering research and has the potential to save lives
    and reduce healthcare costs.
        While each Institute within the NIH plays a vital role researching
    and identifying disease prevention and treatment positively impacting
    patient outcomes; the NIBIB plays a unique role and has not benefited
    from large-scale NIH funding increases, such as the doubling of the
    budget in 2004. First appropriated with its own funding in 2004 (fiscal
    year 2003 and fiscal year 2004 were funded through transfers from other
    Institutes within NIH), the mission of NIBIB is to improve health by
    leading the development and accelerating the application of biomedical
    technologies. The NIBIB is committed to integrating the physical and
    engineering sciences with the life sciences to advance basic research
    and medical care. This is achieved through research and development of
    new biomedical imaging and bioengineering techniques and devices to
    fundamentally improve the detection, treatment, and prevention of
    disease; enhancing existing imaging and bioengineering modalities;
    supporting related research in the physical and mathematical sciences;
    encouraging research and development in multidisciplinary areas;
    supporting studies to assess the effectiveness and outcomes of new
    biologics, materials, processes, devices, and procedures; developing
    nonimaging technologies for early disease detection and assessment of
    health status; and developing advanced imaging and engineering
    techniques for conducting biomedical research at multiple scales
    through modeling and simulation. Finally, the NIBIB plays an important
    role in providing engineering research resources to the entirety of the
    NIH. As the only engineering research arm within the NIH, NIBIB is
    often relied upon to partner with other institutes at the NIH to
    provide engineering expertise. The Laboratory of Molecular Imaging and
    Nanomedicine, and Laboratory of Bioengineering and Physical Science are
    two examples of NIBIB's role as a partner for researchers working at
    other Institutes at the NIH.
        We strongly recommend that early-stage, proof-of-concept projects
    for translational research be funded at an enhanced level, ideally 0.5
    percent of all external research budgets, at all Institutes. This is
    critical to maintaining the U.S. lead in innovation by moving new
    discoveries and novel systems to the stage where third-party private
    funding can take them through development to the marketplace where they
    help patients and health of Americans. Publicly held companies cannot
    invest in this stage of work due to stockholder pressures, so that the
    Federal Government is critical to ensuring the viability of this
    innovation pipeline.
    NIBIB as a Stimulus for Innovation/Cost Effectiveness
        The fiscal year 2010 NIBIB Budget submission is $316.6 million, a
    2.7 percent increase from the fiscal year 2009 appropriation, and is 37
    percent lower than the original 5-year congressional authorization for
    NIBIB funding of $504 million. As the economy worsens, private industry
    and private investors are less likely to invest in high-risk research,
    potentially slowing the pace of innovation. By funding bioengineering
    research, NIBIB fills a void by providing funding for high-risk, high-
    reward research that leads to the development of new technologies.
    Often times, private investors in biomedical innovation are unwilling
    to invest in this type of research, because of the risks involved.
    However, NIBIB can be a mechanism to bring new technologies to market
    and fills the void left by a lack of private capital.
        The NIBIB's Quantum Grants program, for example, challenges the
    research community to propose projects that have a highly focused,
    collaborative, and interdisciplinary approach to solve a major medical
    problem or to resolve a highly prevalent technology-based medical
    challenge. The program consists of a 3-year exploratory phase to assess
    feasibility and identify best approaches, followed by a second phase of
    5 to 7 years. Major advances in medicine leading to quantifiable
    improvements in public health require the kind of funding commitment
    and intellectual focus found in the Quantum Grants program at NIBIB,
    because early stage investors are reluctant to invest in high-risk
    research. That said, the Quantum Grants offer a place for Government to
    invest in translational research, potentially solving huge medical
    problems facing Americans today.
        The five currently funded Quantum Grants focus on: stem cell
    therapies for patients suffering from the effects of diabetes and
    stroke; the utilization of nanoparticles to help visualize brain tumors
    so that surgeons can easily see and remove the cancerous mass in the
    patient's brain; the development of an implantable artificial kidney
    offering an improved quality of life for patients currently undergoing
    dialysis treatment; and a microchip to capture circulating tumor cells
    for clinicians to diagnose cancer earlier than ever before, giving
    patients a greater hope for recovery thanks to earlier detection and
    treatment. All these projects, in their early stages of funding, have
    demonstrated promise for improving patient outcomes in the laboratory
    setting.
        An increase of funding to NIBIB and the Quantum Grants program may
    offer opportunities to expedite research beyond laboratory study and
    move to clinical trial. For example, if this research is developed and
    put on the market, the cost reduction to a person with kidney disease
    would radically decrease because it would eliminate the need for
    dialysis, which is a costly and resource heavy procedure typically done
    in an out-patient hospital setting.
    The Fundamental Role of Engineering Research
        Advances in the process of engineering research, in a variety of
    fields, are a part of technological innovation. Medical and biological
    engineering draws from research specialties across disciplines
    (including mechanical, electrical, material, medical and biological
    engineering, and clinicians), bringing together teams to create unique
    solutions to the most pressing health problems. Engineering is the
    practical application of science and math to solve problems. For
    example, the insulin pump, which is the primary device used by patients
    with diabetes who requires continuous insulin infusion therapy, is the
    result of multi-disciplinary effort by engineers to develop a more
    efficient way to manage diabetes. The science to develop and perfect an
    insulin pump existed well before the creation of the medical device;
    however it took biomedical engineers to apply the basic science toward
    product development.
        The first insulin pump to be manufactured was released in the late
    1970s. It was known as the ``big blue brick'' because of its size and
    appearance. It sparked interest among healthcare professionals who saw
    it as a device that would render syringes obsolete for people who have
    daily insulin injection needs. While the technology was promising, the
    first commercial pump lacked the controls and interface to make it a
    safe alternative to manual injections. Dosage was inaccurate thus
    making the device more of a danger than a solution.
        It was only in the beginning of the 1990's that biomedical
    engineers began to develop more user-friendly models that could be used
    by diabetics. Advances in biomedical engineering research focused on
    reducing device size, increasing energy efficiency (and thus improving
    battery life), and improving reliability were of great benefit to
    insulin pump manufacturers who were able to make their models smaller,
    more affordable, and easier for patients to use. Insulin pumps enable
    many diabetic patients to live productive lives due to fewer absences
    from work and reduced hospitalizations.
        A similar advancement in the treatment of atherolosclerosis through
    MBE is the use of angioplasty with an arterial stent which releases
    drugs directly to the coronary artery (referred to as a drug eluting
    stent). This advancement has replaced more then 500,000 bypass
    surgeries a year, at an annual cost savings of $4 billion, and an
    immeasurable improvement in the quality of life of patients receiving
    this treatment.
        Engineering research in human physiology, specifically in range of
    motion and function, has increased the function for artificial limbs.
    The decreasing mortality and increasing number of disabled war veterans
    highlights the need for more highly functional prosthetics. Engineering
    research and development processes have taken the strapped wooden leg
    to a realistic synergic leg and foot transtibial prosthetic that
    employs advanced biomechanics and microelectronic controls to allow a
    fuller range of motion, including running. Basic engineering research
    in polymers and materials science has changed the look and feel of
    prosthetic limbs so they are no longer easily discernable, reducing the
    stigma, and making them more durable, lessening the cost of maintenance
    and replacement. Researchers in Baltimore, Cleveland and Chicago are
    developing the next generation of prosthetic limbs, utilizing cutting
    edge biomedical engineering research to develop prosthesis that are
    more sensitive, more responsive, and more lifelike then anything
    developed in the past. These new ``bionic limbs'' are giving patients
    pieces of their body back, pieces taken from them through traumatic
    injury or disease. Increases in funding to NIBIB, who uniquely partners
    with other Federal agencies such as the Department of Veterans Affairs
    and Department of Defense, may lead to biomedical engineering
    innovations to improve the quality of life of warfighters injured on
    the battlefield as well as civilians.
        The engineering research process has played a large part in
    extending and deploying innovative imaging technologies such as
    magnetic resonance imaging (MRI) and ultra-fast computerized tomography
    (CT scan). These technologies facilitate early detection of disease and
    dysfunction, allowing for earlier treatment and slowing the progression
    of disease. When prescribed correctly these technologies can reduce the
    costs of healthcare by diagnosing diseases earlier, allowing for
    earlier clinical intervention and reduced hospitalizations with faster
    recovery times.
        The Nation deserves to obtain a strong return on its investment in
    the basic medical research funded by NIH. Additional engineering
    research, including translation of basic research into new devices and
    more efficient medical procedures, is a critical part of ensuring that
    return. This combination of basic scientific studies and engineering
    research, will in turn, lead to many technological innovations which
    will improve the quality of life and well being of Americans. Industry
    will supply developmental engineering research; however, they usually
    do not support the fundamental level of engineering research done at
    NIH and NIBIB due to the high risks to their returning investments. The
    government needs to continue to fund the vital research at NIH and
    NIBIB to continue to be a leader in healthcare innovation, and for the
    creation of jobs in the healthcare segment of our national economy.
        AIMBE looks forward to the opportunity to continue this dialogue
    with all of you individually. Thank you again for your time, and
    consideration on this important matter.
                                     ______

         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,
    and 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 2011 by providing the agency with a total discretionary budget of
    at least $32.239 billion as requested by President Obama. This would be
    a 3.2 percent increase more than the fiscal year 2010 enacted level.
        AIRI is a national organization of 91 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 recent year appropriations bills, Congress has taken
    important steps to jump start the Nation's economy through investments
    in science. 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, which is critically needed to update aging research
    facilities. We urge NIH to continue its commitment to facility,
    equipment, and infrastructure support. The infrastructure that we are
    creating needs to be maintained. Large fluctuations in funding will be
    disruptive to training, to careers, to long range projects and
    ultimately to progress. The research engine needs a predictable,
    sustained investment in science to maximize our return.
        NIH is responding to its charge of stimulating the economy through
    job creation by supporting new scientists. ARRA investments allowed us
    to see firsthand how research is impacting the economy. We cannot stop
    the momentum created by these historic investments. We need to be able
    to continue to advance the new directions charted with the ARRA support
    in 2011 and beyond.
        Keeping up with the rising cost of medical research in the fiscal
    year 2011 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 2011 by at least 3.2 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.
      --High Throughput Technologies.--AIRI Institutes have embraced
            technologies and research centers to collaborate on biological
            research for all diseases. Using advanced technology platforms
            or ``cores,'' AIRI institutes use genomics, imaging, and other
            broad-based technologies for drug discovery.
      --Translational Research.--Translational sciences bridges the divide
            between basic biomedical research and implementation in a
            clinical setting. Currently, more than 15 AIRI member
            institutes are affiliated with and collaborate with the
            Clinical and Translational Science Awards (CTSA) Program. Many
            AIRI institutes also support research on human embryonic stem
            cells (hESC) with the hope of discovering new and innovative
            disease interventions.
      --Using Science to Enable Health Care Reform.--As basic biomedical
            research institutes, AIRI members collaborate with other
            research partners on patient-centered outcomes research. AIRI
            members act as the basic research arm for disease treatment
            (for example, by supporting genetic testing), while other
            project collaborators study other aspects of disease
            intervention in an effort to learn the best practices for
            preventing and treating disease.
      --Global Health.--AIRI member institutes focus on a wide range of
            diseases, many of which have a global affect on human health.
            Besides supporting research for the treatments, vaccines, and
            cures of the world's deadliest diseases, a number of AIRI
            institutes partner with research institutions in the developing
            world to support international disease research, such as
            collaborations on HIV/AIDS, Tuberculosis, and Malaria.
      --Reinvigorating the Biomedical Research Community.--AIRI supports
            policies that promote the United States' ability to maintain a
            competitive edge in biomedical science. The biomedical research
            community is dependent upon a knowledgeable, skilled, and
            diverse workforce to address current and future critical health
            research questions. The cultivation and preservation of this
            workforce is dependent upon the ability to recruit scientists
            and students globally as well as training programs in basic and
            clinical biomedical research. Initiatives focusing on career
            development and recruiting a diverse scientific workforce are
            important to innovation in biomedical research for the benefit
            of public health.
        Providing Efficiency and Flexibility.--AIRI member institutes'
    small size and valuable 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 2011
    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 American Lung Association

                              SUMMARY OF PROGRAMS

    Centers for Disease Control and Prevention (CDC)
        Increased overall CDC funding--$8.8 billion
      --Funding CDC COPD Program--$3 million
      --Funding Healthy Communities--$52.8 million
      --Office on Smoking and Health--$280 million
      --Asthma programs--$70 million
      --Environment and Health Outcome Tracking--$50 million
      --Tuberculosis programs--$220.5 million
      --CDC Influenza preparedness--$159.1 million
      --NIOSH--$364.3 million
    National Institutes of Health (NIH)
        Increased overall NIH funding--$35 billion
      --National Heart, Lung and Blood Institute--$3.514 billion
      --National Cancer Institute--$5.725 billion
      --National Institute of Allergy and Infectious Diseases--$5.395
            billion
      --National Institute of Environmental Health Sciences--$779.4 million
      --National Institute of Nursing Research--$163 million
      --National Center on Minority Health & Health Disparities--$236.9
            million
      --Fogarty International Center--$78.4 million
        The American Lung Association is pleased to present our
    recommendations to the Labor, Health and Human Services, and Education,
    and Related Agencies Appropriations Subcommittee. The public health and
    research programs funded by this subcommittee will prevent lung disease
    and improve and extend the lives of millions of Americans who suffer
    from lung disease.
        The American Lung Association is the oldest voluntary health
    organization in the United States, with national offices and local
    associations around the country. Founded in 1904 to fight tuberculosis,
    the American Lung Association today fights lung disease in all its
    forms through research, advocacy and education.

                     A SUSTAINED AND SUSTAINABLE INVESTMENT

        We thank the chairman and the subcommittee for your leadership in
    healthcare reform and the priority paid to prevention and wellness. The
    investments this committee makes can and will pay near-term and long-
    term dividends for the health of the American people.
        Specifically, we want to highlight the need for the American
    Recovery and Reinvestment (ARRA) funds to be incorporated into base
    funding levels in order to sustain these critical investments,
    particularly for the Center for Disease Control and Prevention's public
    health programs. These investments in prevention and wellness are
    crucial to ensuring a healthier population and a reduction in
    healthcare costs. Chronic disease is a huge driver of cost and human
    suffering and incorporating the ARRA funds into the baseline will allow
    sustained investments in proven interventions like smoking cessation.
        The United States must also maintain its renewed commitment to
    medical research. While our focus is on lung disease research, we
    strongly support increasing the investment in research across the
    entire National Institutes of Health.

                                  LUNG DISEASE

        Each year, almost 400,000 Americans die of lung disease. It is
    responsible for 1 in every 6 deaths. More than 35 million Americans
    suffer from a chronic lung disease. Each year lung disease costs the
    economy an estimated $173 billion. Lung diseases include: lung cancer,
    asthma, chronic obstructive pulmonary disease (COPD), tuberculosis,
    pneumonia, influenza, sleep disordered breathing, pediatric lung
    disorders, occupational lung disease and sarcoidosis.

                            IMPROVING PUBLIC HEALTH

        The American Lung Association strongly supports investments in the
    public health infrastructure. In order for the CDC to carry out its
    prevention mission, and to assure an adequate translation of new
    research into effective State and local programs to improve the health
    of all Americans, we strongly support increasing the overall CDC
    funding to $8.8 billion.
        We strongly encourage improved disease surveillance and health
    tracking to better understand diseases like asthma. We support an
    appropriations level of $50 million for the Environment and Health
    Outcome Tracking Network to allow Federal, State, and local agencies to
    track potential relationships between hazards in the environment and
    chronic disease rates.
        We strongly support investments in communities to bring together
    key stakeholders to identify and improve policies and environmental
    factors influencing health in order to reduce the burden of chronic
    diseases. These programs lead to a wide range of improved health
    outcomes including reduced tobacco use. We strongly recommend at least
    $52.8 million in funding for the Healthy Communities program to expand
    its reach to more communities.

                     CHRONIC OBSTRUCTIVE PULMONARY DISEASE

        Chronic Obstructive Pulmonary Disease, or COPD, is the fourth
    leading cause of death both in the United States and worldwide. Yet, it
    remains relatively unknown to most Americans. COPD refers to a group of
    largely preventable diseases, including emphysema and chronic
    bronchitis that gradually limit the flow of air in the body. It has
    been estimated that 12.1 million patients have been diagnosed with some
    form of COPD and as many as 24 million adults may suffer from its
    consequences. In 2006, 120,970 people in the United States died of
    COPD. The annual cost to the nation for COPD in 2010 is projected to be
    $49.9 billion. Medicare expenses for COPD beneficiaries were nearly 2.5
    times that of the expenditures for all other patients.
        Despite the enormity of this problem, COPD receives far too little
    attention at CDC or in health departments across the Nation. The
    American Lung Association strongly supports the establishment of a
    national COPD program within CDC's National Center for Chronic Disease
    Prevention and Health Promotion with a specific line item of $3 million
    for fiscal year 2011 to create a comprehensive national action plan for
    combating COPD. Creating this plan will address the public health role
    in prevention, treatment and management of this disease.
        Today, COPD is treatable but not curable. Despite promising
    research leads, the American Lung Association believes that research
    resources committed to COPD are not commensurate with the impact COPD
    has on the United States and the world. The American Lung Association
    strongly recommends that the NIH and other Federal research programs
    commit additional resources to COPD research programs. We strongly
    support funding the National Heart, Lung and Blood Institute and its
    lifesaving lung disease research program at $3.514 billion.

                                  TOBACCO USE

        Tobacco use is the leading preventable cause of death in the United
    States, killing more than 443,000 people every year. Smoking is
    responsible for 1 in 5 U.S. deaths. The direct healthcare and lost
    productivity costs of tobacco-caused disease and disability are also
    staggering, an estimated $193 billion each year.
        Given the magnitude of the tobacco-caused disease burden and how
    much of it can be prevented; the CDC Office on Smoking and Health
    should be much larger and better funded. This neglect cannot continue
    if the nation wants to prevent disease and promote wellness. Public
    health interventions have been scientifically proven to reduce tobacco
    use.
        In light of new funds available from the Patient Protection and
    Affordable Care Act and the subcommittee's fiscal year 2010 request to
    OSH for a 5-year plan to significantly reduce tobacco use in the United
    States, the American Lung Association urges that a minimum of $280
    million be appropriated to CDC's Office on Smoking and Health for
    fiscal year 2011.

                                  LUNG CANCER

        An estimated 364,996 Americans are living with lung cancer. During
    2009, an estimated 219,440 new cases of lung cancer were diagnosed, and
    158,664 Americans died from lung cancer in 2006. Survival rates for
    lung cancer tend to be much lower than those of most other cancers and
    significant health disparities exist in the incidence and treatment of
    this disease.
        Lung cancer receives far too little attention and focus. Given the
    magnitude of lung cancer and the enormity of the death toll, the
    American Lung Association strongly recommends that the NIH and other
    Federal research programs commit additional resources to lung cancer.
    We support a funding level of $5.725 billion for National Cancer
    Institute and urge more attention and focus on lung cancer.

                                     ASTHMA

        Asthma is a chronic lung disease in which the bronchial tubes
    become swollen and narrowed, preventing air from getting into or out of
    the lung. Approximately 23.3 million Americans currently have asthma,
    of which 12.7 million had an asthma attack in 2008. Asthma is expensive
    and incurs an estimated annual economic cost of $20.7 billion to our
    Nation. Asthma is the third leading cause of hospitalization among
    children under the age of 15. It is also one of the leading causes of
    school absences. The Federal response to asthma has three components:
    research, programs and planning.
        We recommend that the National Heart, Lung and Blood Institute
    receive $3.514 billion and the National Institute of Allergy and
    Infectious Diseases be appropriated $5.395 billion, and that both
    agencies continue their investments in asthma research in pursuit of
    treatments and cures.
        The American Lung Association also recommends that CDC be provided
    $70 million in fiscal year 2011 to expand its asthma programs.

                                   INFLUENZA

        Influenza is a highly contagious viral infection and one of the
    most severe illnesses of the winter season. It is responsible for an
    average of 226,000 hospitalizations and 36,000 deaths each year.
    Further, the emerging threat of a pandemic influenza is looming as the
    recently emerging strain of H1N1 reminded us. The American Lung
    Association supports funding the Federal CDC Influenza efforts at $156
    million. We also support investments in influenza totaling $45 million
    for the Food and Drug Administration (FDA), $35 billion for the
    National Institutes of Health (NIH), and $66 million for the Office of
    the Secretary, as proposed in the President's budget.

                                  TUBERCULOSIS

        Tuberculosis primarily affects the lungs but can also affect other
    parts of the body. There are an estimated 10 million to 15 million
    Americans who carry latent TB infection. Each has the potential to
    develop active TB in the future. In 2008, there were 12,904 cases of
    active TB reported in the United States. While declining overall TB
    rates are good news, the emergence and spread of multi-drug resistant
    TB pose a significant threat to the public health of our Nation.
    Continued support is needed if the United States. is going to continue
    progress toward the elimination of TB. We request that Congress
    increase funding for tuberculosis programs at CDC to $220.5 million.

                                   CONCLUSION

        Mr. Chairman, lung disease is a continuing, growing problem in the
    United States. It is America's number three killer, responsible for 1
    in 6 deaths. Progress against lung disease is not keeping pace with
    other major causes of death and more must be done. The level of support
    this subcommittee approves for lung disease programs should reflect the
    urgency illustrated by these numbers.
                                     ______

              Prepared Statement of the American Liver Foundation

        Mr. Chairman and members of the subcommittee, thank you for giving
    the American Liver Foundation the opportunity to provide testimony as
    the subcommittee begins to consider funding priorities for fiscal year
    2011. My name is Dr. Allan Wolkoff and I am the Chairman of the Board
    of Directors of the American Liver Foundation (ALF), a national
    voluntary health organization dedicated to the prevention, treatment
    and cure of hepatitis and other liver diseases through research,
    education and advocacy. I am also a Professor of Medicine and Chief of
    the Division of Hepatology at the Albert Einstein College of Medicine.
        ALF has a nationwide network of divisions and provides information
    to 300,000 patients and families. More than 70,000 physicians,
    including primary care practitioners and liver specialists and
    scientists also receive information from ALF. The ALF Board of
    Directors is composed of scientists, clinicians, patients and others
    who are directly affected by liver diseases. Every year ALF handles
    more than 100,000 requests for information, helping patients and their
    families understand their illnesses, informing them about available
    services, and showing them that there are knowledgeable and concerned
    individuals to assist them in every possible way.
        Mr. Chairman, ALF joins the Ad Hoc Group for Medical Research
    Funding, a coalition of some 300 patient and voluntary health groups,
    medical and scientific societies, academic research organizations and
    industry, in recommending $35 billion in funding for the National
    Institutes of Health in fiscal year 2011. While the ALF recognizes the
    demands on our Nation's resources, we believe the ever-increasing
    health threats and expanding scientific opportunities continue to
    justify increased funding levels for the National Institutes of Health
    (NIH). To ensure that NIH's momentum is not further eroded, and to
    ensure the fight against diseases and disabilities that affect millions
    of Americans can continue, ALF supports $35 billion for the NIH in
    fiscal year 2011 and a minimum increase of 12 percent ($235 million)
    for the National Institute for Diabetes and Digestive and Kidney
    Diseases and for liver disease research across all NIH Institutes.
        In addition to the NIH, there are a number of programs within the
    jurisdiction of the subcommittee that are important to ALF including
    the Centers for Disease Control's Division of Viral Hepatitis and the
    Health Resources Services Administration. Mr. Chairman, our specific
    recommendations for these and other areas of interest are summarized in
    a table at the end of this statement.

                 RECOGNIZING THE LEADERSHIP OF THE SUBCOMMITTEE

        Mr. Chairman, ALF appreciates your leadership and the leadership of
    this Subcommittee in supporting NIH in a time of fiscal austerity. Your
    leadership in supporting CDC and HRSA are also greatly recognized and
    appreciated. These programs are important to our shared goals of
    improving the public health response to the threats of hepatitis and
    liver disease and to increasing the rate of organ donation. We applaud
    the subcommittee's leadership in making progress in these important
    areas and to allocating increased funding to these programs during
    periods of fiscal austerity.

      A NATIONAL STRATEGY FOR PREVENTION AND CONTROL OF HEPATITIS B AND C.

        The ALF is very pleased that the Office of the Secretary has
    convened and established an inter-departmental task-force to address
    the public health challenge of viral hepatitis. This is an important
    step for the Department to take to develop a comprehensive response to
    the challenge of hepatitis. In January 2010, the Institute of Medicine
    released a groundbreaking report titled ``Hepatitis and Liver Cancer: A
    National Strategy for Prevention and Control of Hepatitis B and C''
    documenting the problem and highlighting a course of action to address
    it. ALF urges its review and consideration by the Task Force. ALF also
    urges the Committee to request an update from the Task Force of their
    recommendations and actions and further urges the Committee to review
    and address the chronic underfunding of viral hepatitis prevention
    programs within the Department, including the National Institutes of
    Health and the CDC's Division of Viral Hepatitis.

    THE NATIONAL INSTITUTES OF HEALTH AND THE LIVER DISEASE RESEARCH ACTION
                                      PLAN

        We depend upon the NIH to fund research that will lead to new and
    more effective interventions to treat people with liver diseases. The
    American Liver Foundation joins with the Ad Hoc Group for Biomedical
    Research and requests a funding level of $35 billion for the NIH in
    fiscal year 2011.
        We thank the subcommittee for their continued investment in NIH in
    fiscal year 2010. Sustaining progress in medical research is essential
    to the twin national priorities of smarter healthcare and economic
    revitalization. With additional investment, the nation can seize the
    unique opportunity to build on the tremendous momentum emerging from
    the strategic investment in NIH made through the 2009 American Recovery
    and Reinvestment Act (ARRA). NIH invested those funds in a range of
    potentially revolutionary new avenues of research that will lead to new
    early screenings and new treatments for disease.
        In fiscal year 2009, NIH spent approximately $651 million on liver
    disease research overall (ARRA and non-ARRA funds), and estimates that
    in fiscal year 2010 $635 million will be spent. This includes research
    for viral hepatitis, liver cancer, and a host of other liver diseases.
    An additional $235 million (12 percent increase) for the National
    Institute of Diabetes and Digestive and Kidney Diseases, the Institute
    with lead on liver disease research, could make transformational
    advances in research leading to better treatments for people with liver
    disease. The ALF recommends that in fiscal year 2011 the National
    Institute of Diabetes and Digestive and Kidney Diseases be funded at
    $2,192,247,000 and that overall NIH funding total $35 billion.
        Mr. Chairman, in December of 2004, the NIDDK released the Liver
    Disease Research Action Plan outlining major research goals for the
    various aspects of liver disease. Working with the leading scientific
    experts in the field, the plan is organized into 16 chapters and
    identifies numerous areas of research important to virtually every
    aspect of liver disease, including: improving the success rate of
    therapy of hepatitis C; developing noninvasive ways to measure liver
    fibrosis; developing sensitive and specific means of screening
    individuals at high risk for early hepatocellular carcinoma; developing
    standardized and objective diagnostic criteria for major liver diseases
    and their grading and staging; and decreasing the mortality rate from
    liver disease. Each year, the plan is reviewed and updated. The ALF
    urges the Committee to provide adequate funding and policy guidance to
    NIH to urge continued implementation of the plan.

                       CDC'S DIVISION OF VIRAL HEPATITIS

        The Division of Viral Hepatitis (DVH) is included in the National
    Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the
    CDC, and is responsible for the prevention and control of viral
    hepatitis, a disease which impacts more than 6 million Americans and
    often leads to liver cancer and liver failure. The DVH provides the
    scientific and programmatic foundation for the prevention, control and
    elimination of hepatitis virus infections in the United States and also
    assists the international public health community in these activities.
    DVH works with State and local health departments to provide the
    guidance and technical expertise needed to integrate hepatitis
    prevention services such as hepatitis A and B vaccine, hepatitis B and
    C counseling, and testing and referral to existing public health
    programs serving individuals at high risk.
        DVH is currently funded at $19.3 million, $6 million less than its
    funding level in fiscal year 2003, which does not allow for the
    provision of core prevention services. The ALF joins the hepatitis
    community and urges a fiscal year 2011 funding level for the Division
    of Viral Hepatitis of $50 million.

                  INCREASING THE SUPPLY OF ORGANS FOR DONATION

        As the subcommittee knows, even with advances in the use of living
    liver donors, the increase in the demand for livers needed for
    transplantation will continue to exceed the number available. The need
    to increase the rate of organ donation is critical. On April 9, 2010
    there were 106,917 men, women and children on the national
    transplantation waiting list. Last year an average of 80 patients were
    transplanted each day; however a daily average of 18 patients died
    because the organ they needed did not become available in time to save
    them. The shortage of organs for donation can be positively impacted by
    healthcare professionals, particularly physicians, nurse, and physician
    assistants that are frequently the first to identify and refer a
    potential donor. These professionals also have an established
    relationship with the family members that weigh the option to donate
    their loved one's organs. In order to improve the knowledge and skills
    of the several key health professions, ALF requests funding to develop
    curriculum and continuing medical education programs for targeted
    health professions. To launch a new five year effort to improve the
    competency of health professionals to help meet the goal of increasing
    the number or organs available for transplantation $450,000 is
    requested for the United Network for Organ Sharing (UNOS) to be made
    available from within the Division of Health Professions set aside
    authority for technical assistance.

                             SUMMARY AND CONCLUSION

        Mr. Chairman, again we wish to thank the subcommittee for its past
    leadership. Significant progress has been made in developing better
    treatments and cures for the diseases that affects mankind due to your
    leadership and the leadership of your colleagues on this subcommittee.
    Significant progress has also similarly been made in the fight against
    liver disease. For fiscal year 2011 we recommend a 12 percent, increase
    for NIH above the level of the fiscal year 2010 funding levels, with
    the level of liver disease research also increased by at least 12
    percent. We also urge a $50 million for the CDC's Division of Viral
    Hepatitis to strengthen the public health response to hepatitis and
    liver disease and a $2 million increase to HRSA's Division of
    Transplantation, as well as $450,000 for the Division of Health
    Professions to increase the rate of organ donation. Mr. Chairman, if
    this country is to maintain its leadership role in health maintenance,
    disease prevention, and the curing of diseases, adequate funding for
    NIH, CDC and HRSA is paramount. The ALF appreciates the opportunity to
    provide testimony to you on behalf of our constituents and yours.

                ALF RECOMMENDATIONS FOR FISCAL YEAR 2010 FUNDING

        NIH and the Liver Disease Research Action Plan: $35 billion for NIH
    overall and 12 percent increase for the National Institute of Diabetes
    and Digestive and Kidney Diseases; and +$25 million to implement the
    Liver Research Action Plan.
        CDC: National Hepatitis C Prevention Strategy, Public Health
    Information, HAV & HBV Vaccinations: Fund the CDC's Division of Viral
    Hepatitis at $50 million to strengthen the public health response to
    chronic viral hepatitis.
        HRSA: Expanding the supply or organs: +$450,000 for an organ
    donation curriculum development initiative at HRSA's Division of Health
    Professions.
                                     ______

             Letter From the American Mosquito Control Association
                                                        April 12, 2010.
    Hon. Tom Harkin,
    Chairman, Labor, Health and Human Services, Education, and Related
            Agencies Subcommittee, Washington, DC.
        Dear Chairman Harkin: On behalf of the American Mosquito Control
    Association, I am writing to ask your assistance in maintaining $26.7
    million in funding for controlling vector-borne diseases including West
    Nile Virus (WNV) under the fiscal year 2011 Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill.
        The American Mosquito Control Association represents an
    international association of individuals and organizations interested
    in mosquito and other vector control. Our mission is to provide
    leadership, information, and education leading to the enhancement of
    public health and quality of life through the suppression of mosquitoes
    and other vectors.
        Since 1999, there have been more than 29,000 documented cases of
    WNV in the United States.
        Almost 12,000 of those cases have involved West Nile Neuroinvasive
    Disease, the most severe form. It is estimated that 1.65 million people
    in the United States have been infected with and 1,122 people have died
    from WNV since 1999. It is believed that WNV will continue to
    intermittently produce local or regional epidemics resulting in
    thousands of human cases.
        Since 2000, appropriated funds have been provided to the Centers
    for Disease Control and Prevention for distribution to States to assist
    them in developing and sustaining public health infrastructure to
    reduce risk of WNV. These funds are used for surveillance and
    monitoring of mosquito populations and the presence of WNV, for virus
    testing, and for applied research. Many State public health agencies
    and State, county, or municipal mosquito control programs depend upon
    these funds to contend with WNV, and have also utilized this support to
    develop capacity to deal with exotic diseases transmitted by insects
    that may be introduced into the country.
        However, the President's budget recommendation for fiscal year 2011
    eliminates all of the current $26.7 million of this funding. Given the
    virulence of WNV, coupled with the fiscal strain already put on States
    due to various economic factors, we respectfully request that the
    Labor, Health and Human Services, and Education, and Related Agencies
    Appropriations Subcommittee resist elimination of any of this funding
    for fiscal year 2011. Any savings provided by eliminating this
    essential funding will be insignificant compared to the losses suffered
    if the mosquito vector populations that spread WNV are not adequately
    suppressed.
        Thank you for your consideration of this urgent public health
    matter.
                Sincerely,
                                                   David Brown,
                                                              Chairman.
                                     ______

      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 and 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 an increase in funding for the Title V Maternal
    and Child Health Services Block Grant to $730 million for Federal
    fiscal year 2011.
        To help illustrate the importance of Title V MCH Block Grant
    funding, I want to begin by sharing the story of a girl from Iowa who
    was helped by title V-supported 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--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 thousands of children,
    children with special healthcare needs and pregnant women that are
    served by Title V MCH Block Grant programs in Chairman Harkin's State
    alone. The Title V MCH Block Grant supports a similar network in my
    home State of Florida, and none of this could happen without Title V
    MCH Block Grant funding.
        Health reform was a great step forward in advancing the health of
    women and children but America still faces huge challenges in 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. Today the United States ranks 30th in infant
    mortality rates and 41st in maternal mortality 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, the United States still fails
    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.
        Health reform will increase coverage and work to improve access to
    healthcare and services for millions of Americans and Title V MCH Block
    Grant programs have the expertise to assure that women's and children's
    specific needs are addressed as programs are implemented. MCH is
    uniquely positioned to support and strengthen health reform by:
      --Ensuring that improvements in health, not just healthcare, are
            realized through health reform. Coverage and access to medical
            care have only a limited impact on overall population health.
            Within the maternal and child health community, many States are
            seeing that early access to quality prenatal care services is
            no longer adequate to assure healthy birth outcomes for high-
            risk women. Despite expanded access to healthcare for pregnant
            women, the infant mortality rate in America has not improved
            significantly in the past decade. Programs funded by the Title
            V MCH Block Grant can help assure statewide implementation of
            primary prevention strategies including public information and
            education efforts targeted to populations at risk. Title V MCH
            Block Grant can help guide implementation of systems of
            comprehensive secondary prevention services (including newborn
            screening and counseling; regionalized systems of perinatal and
            neo-natal high-risk services; high-risk tracking and follow-up
            services; early intervention services; and infectious disease
            control).
      --Offering leadership and support for outreach, enrollment, and
            access to family-centered care. All children will now have
            health insurance coverage and Title V MCH Block Grant programs
            can help reach out to those children and their families to help
            them access the healthcare system. Since the 1990's Title V MCH
            leaders have been instrumental in supporting the Bright Futures
            initiative that sets a standard of care for kids and children
            with special healthcare needs. In health reform, co-pays for
            these preventive care and screening guidelines were eliminated,
            showing that Congress recognizes the importance of this
            national health promotion and Maternal and child health
            programs at the State level will support and promote The Bright
            Futures guidelines by offering training to children's health
            professionals. Many already insured individuals report they do
            not have a usual source of care. Only 50 percent of Children
            with Special Health Care Needs report that they 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. Those with special needs often need additional
            services and care coordination not typically covered by health
            insurance.
      --Assessing the health status of women and children by conducting
            data collection, surveillance, and monitoring activities
            related to MCH population health measurement and outcomes.
            Title V MCH Block Grant programs regularly collect and report
            on public health measures, vital statistics, and personal
            health services data and use this information to inform state
            and local program planning.
        Without increased funding, Title V MCH Block Grant Programs will be
    overwhelmed by this work if they are not provided the resources they
    need. AMCHP asks for your leadership in providing States the funding
    they need by increasing the Title V MCH Block Grant to $730 million for
    fiscal year 2011. We have a track record of demonstrating that we make
    a positive difference and are fully accountable for the funds that we
    receive. Increasing the funding to the Title V 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 Title V 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 website
    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 Title V 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 Title V MCH Block Grant funded programs. Due to years
    of reduced investment, the Title V MCH Block Grant is at its lowest
    funding level since 1993, $662 million, meaning States again are being
    asked to continue to serve additional people with less.

        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 Title V MCH Block Grant aims
    to do just that--using resources effectively to improve the health of
    all of America's women and children. Investing in the Title V MCH Block
    Grant is a cost-effective investment in our Nation's future, and we
    again appreciate your leadership to fund it at to $730 million for
    Federal fiscal year 2011. Thank you.
                                     ______

     Prepared Statement of the Association of Minority Health Professions
                                    Schools

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Leo Rouse,
    Chairman of the Association of Minority Health Professions Schools
    (AMHPS) and the dean of the college of dentistry at Howard University.
    AMHPS, established in 1976, is a consortium of our Nation's 12
    historically black medical, dental, pharmacy, and veterinary schools.
    The members are two dental schools at Howard University and Meharry
    Medical College; four schools of medicine at The Charles Drew
    University, Howard University, Meharry Medical College, and Morehouse
    School of Medicine; five schools of pharmacy at Florida A&M University,
    Hampton University, Howard University, Texas Southern University, and
    Xavier University; and one school of veterinary medicine at Tuskegee
    University. In all of these roles, I have seen firsthand the importance
    of minority health professions institutions and the Title VII Health
    Professions Training programs.
        Mr. Chairman, time and time again, you have encouraged your
    colleagues and the rest of us to take a look at our Nation and evaluate
    our needs over the next 10 years. I want to say that minority health
    professional institutions and the Title VII Health Professionals
    Training programs address a critical national need. Persistent and
    severe staffing shortages exist in a number of the health professions,
    and chronic shortages exist for all of the health professions in our
    Nation's most medically underserved communities. Furthermore, even
    after the landmark passage of health reform, it is important to note
    that our Nation's health professions workforce does not accurately
    reflect the racial composition of our population. For example while
    blacks represent approximately 15 percent of the U.S. population, only
    2-3 percent of the Nation's health professions workforce is black. Mr.
    Chairman, I would like to share with you how your subcommittee can help
    AMHPS continue our efforts to help provide quality health professionals
    and close our Nation's health disparity gap.
        There is a well-established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than nonminority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas; (2) provide care
    for minorities; and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        In fiscal year 2011, funding for the Title VII Health Professions
    Training programs must be restored to the fiscal year 2005 level of at
    least $300 million, with two programs--the Minority Centers of
    Excellence (COEs) and Health Careers Opportunity Program (HCOPs)--in
    particular need of further funding restoration. In addition, the
    National Institutes of Health (NIH)'s National Institute on Minority
    Health and Health Disparities (NIMHD), as well as the Department of
    Health and Human Services (HHS)'s Office of Minority Health (OMH), are
    both in need of a funding increase.
        Minority Centers of Excellence (COE).--COEs focus on improving
    student recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions to the training
    of minorities in the health professions. Congress later went on to
    authorize the establishment of ``Hispanic'', ``Native American'' and
    ``Other'' Historically black COEs. For fiscal year 2011, I recommend a
    funding level of $33.6 million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and nonminority health profession institutions to support
    pipeline, preparatory, and recruiting activities that encourage
    minority and economically disadvantaged students to pursue careers in
    the health professions. Many HCOPs partner with colleges, high schools,
    and even elementary schools in order to identify and nurture promising
    students who demonstrate that they have the talent and potential to
    become a health professional. For fiscal year 2011, I recommend a
    funding level of $35.6 million for HCOPs.
    National Institutes of Health (NIH): Extramural Facilities Construction
        Mr. Chairman, if we are to take full advantage of the recent
    funding increases for biomedical research that Congress has provided to
    NIH over the past decade, it is critical that our Nation's research
    infrastructure remain strong. The current authorization level for the
    Extramural Facility Construction program at the National Center for
    Research Resources is $250 million. The law also includes a 25 percent
    set-aside for ``Institutions of Emerging Excellence'' (many of which
    are minority institutions) for funding up to $50 million. Finally, the
    law allows the NCRR Director to waive the matching requirement for
    institutions participating in the program. We strongly support all of
    these provisions of the authorizing legislation because they are
    necessary for our minority health professions training schools. In
    fiscal year 2011, please provide a funding appropriation of $50 million
    for extramural facilities.
        Research Centers in Minority Institutions.--The Research Centers at
    Minority Institutions program (RCMI) at the National Center for
    Research Resources has a long and distinguished record of helping our
    institutions develop the research infrastructure necessary to be
    leaders in the area of health disparities research. Although NIH has
    received unprecedented budget increases in recent years, funding for
    the RCMI program has not increased by the same rate. Therefore, the
    funding for this important program grow at the same rate as NIH overall
    in fiscal year 2011.
        Strengthening Historically Black Graduate Institutions--Department
    of Education.--The Department of Education's Strengthening Historically
    Black Graduate Institutions program (title III, part B, section 326) is
    extremely important to AMHPS. The funding from this program is used to
    enhance educational capabilities, establish and strengthen program
    development offices, initiate endowment campaigns, and support numerous
    other institutional development activities. In fiscal year 2011, an
    appropriation of $75 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        National Center on Minority Health and Health Disparities
    (NCMHD).--NCMHD is charged with addressing the longstanding health
    status gap between minority and nonminority populations. The NCMHD
    helps health professional institutions to narrow the health status gap
    by improving research capabilities through the continued development of
    faculty, labs, and other learning resources. The NCMHD also supports
    biomedical research focused on eliminating health disparities and
    develops a comprehensive plan for research on minority health at the
    NIH. Furthermore, the NCMHD provides financial support to health
    professions institutions that have a history and mission of serving
    minority and medically underserved communities through the Minority
    Centers of Excellence program. For fiscal year 2011, I recommend a
    funding level of $500 million for the NCMHD.
        Department of Health and Human Services' Office of Minority Health
    (OMH).--Specific programs at OMH include: assisting medically
    underserved communities with the greatest need in solving health
    disparities and attracting and retaining health professionals;
    assisting minority institutions in acquiring real property to expand
    their campuses and increase their capacity to train minorities for
    medical careers; supporting conferences for high school and
    undergraduate students to interest them in health careers, and
    supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2011, I recommend a funding level
    of $75 million for the OMH.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    AMHPS's member institutions and the Title VII Health Professions
    Training programs can help this country to overcome health disparities.
    Congress must be careful not to eliminate, paralyze or stifle the
    institutions and programs that have been proven to work. The
    Association seeks to close the ever widening health disparity gap. If
    this subcommittee will give us the tools, we will continue to work
    towards the goal of eliminating that disparity everyday.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

             Prepared Statement of the American Nurses Association

        The American Nurses Association (ANA) appreciates this opportunity
    to comment on fiscal year 2011 appropriations for nursing education,
    workforce development, and research programs. Founded in 1896, ANA is
    the only full-service professional association representing the
    interests of the Nation's 3.1 million registered nurses (RNs) through
    its constituent member nurses associations, its organizational
    affiliates, and its workforce advocacy affiliate, the Center for
    American Nurses. The ANA advances the nursing profession by fostering
    high standards of nursing practice, promoting the rights of nurses in
    the workplace, projecting a positive and realistic view of nursing, and
    by lobbying the Congress and regulatory agencies on healthcare issues
    affecting nurses and the public.
        The ANA gratefully acknowledges this subcommittee's history of
    support for nursing education and research. We also appreciate your
    continued recognition of the important role nurses play in the delivery
    of quality healthcare services. This testimony will provide 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 Bureau of Labor Statistics reports that registered nursing will
            have remarkable job growth in the time period spanning 2006-
            2016. During this time decade, 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.
    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.
    ANA strongly urges Congress to increase funding for title VIII programs
    by at least $23 million (10 percent increase) to a total of $267.3
    million in fiscal year 2011.
        Current funding levels are clearly failing to meet the need. In
    fiscal year 2008 (most recent year statistics are available), 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 three times the fiscal year 2010
    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:
        NELRP and Scholarships.--This line item is comprised of the NELRP
    and the NSP. In fiscal year 2010, the NELRP s received $93.8 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 NELRP, the NSP has been stunted by a
    lack of funding. In fiscal year 2008, HRSA received 3,039 applications
    for the NSP. 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
    2010, this program received $25 million.
        This program is vital given the critical shortage of nursing
    faculty. America's schools of nursing cannot 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. 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. All together, the Nurse Education, Practice, and
    Retention Grants supported 42,761 nurses and nursing students in fiscal
    year 2008. The program received $39.8 million in fiscal year 2010.
        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 2010, 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, 5,649 advanced education nurses were supported
    through these programs. In fiscal year 2010, these programs received
    $64.4 million.
        These grants also provide traineeships for master's 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 2008, 6,514 nurses and nursing students were supported through
    these programs. In fiscal year 2010, 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.
    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. In preparation for
    the implementation of healthcare reform initiatives, which ANA
    supported, we believe there will be an even greater need for nurses and
    adequate funding for these programs is even more essential. ANA asks
    you to meet today's shortage with a relatively modest investment of
    $267.3 million in title VIII programs. Thank you.
                                     ______

             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, and UNICEF--founded 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 700 million children. Largely
    due to the Measles Initiative, global measles mortality dropped 78
    percent, from an estimated 733,000 deaths in 2000 to 164,000 in 2008.
    During this same period, measles deaths in Africa fell by 92 percent,
    from 371,000 to 28,000.
    ---------------------------------------------------------------------------
        \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 $720 million
    and provided technical support in more than 60 developing countries on
    vaccination campaigns, surveillance and improving routine immunization
    services. From 2000 to 2008, an estimated 4.3 million measles deaths
    were averted as a result of these accelerated measles control
    activities 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 opportunity 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 (reduces
    malnutrition), 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 40 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.
        By the end of 2008 all WHO regions, with the exception of one
    (South East Asia), achieved the 2010 goal 2 years ahead of target. The
    extraordinary reduction in global measles deaths contributed an
    estimated 25 percent of the progress to date toward Millennium
    Development Goal #4 (reducing under 5 child mortality). However, at the
    height of global achievements in measles control, a sharp decline in
    commitments threatens to erase the gains of the last decade and a
    global measles resurgence is likely. If mass immunization campaigns are
    not continued, an estimated 1.7 million measles-related deaths could
    occur between 2010-13, with more than half a million deaths in 2013
    alone.
        To achieve the 2010 goal and avoid a resurgence of measles the
    following actions are required:
      --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 mass immunization
            campaigns.
      --Securing sufficient funding for measles-control activities both
            globally and nationally. The Measles Initiative faces a funding
            shortfall of an estimated $47 million for 2011. Implementation
            of timely measles campaigns is increasingly dependent upon
            countries funding these activities locally. The decrease in
            donor funds available at global level to support measles
            elimination activities 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 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, several measles outbreaks in the United
    States, all linked to importation of the virus from overseas, led to
    the largest number of U.S. measles cases since 1996. These cases
    resulted in dozens of hospitalizations and the costs of response to the
    outbreaks were substantial, both in terms of the costs to public health
    departments and in terms of productivity losses among people with
    measles, parents of sick children, and people exposed to measles cases.
    The Role of CDC in Global Measles Mortality Reduction
        Since fiscal year 2001, Congress has provided approximately $43.6
    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 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 8 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 2010, Congress has appropriated approximately $51.9
    million to fund CDC for global measles control activities. The American
    Red Cross and the United Nations Foundation thank Congress for the
    increase in financial support from past years. We respectfully request
    level funding for fiscal year 2011 for CDC's measles control activities
    to prevent a global resurgence of measles and a loss of progress toward
    Millennium Development Goal #4.
        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 Americans for Nursing Shortage Relief

        The undersigned organizations of the ANSR Alliance greatly
    appreciate the opportunity to submit written testimony regarding fiscal
    year 2011 appropriations for Title VIII--Nursing Workforce Development
    Programs. We represent a diverse cross-section of healthcare and other
    related organizations, healthcare providers, and supporters of nursing
    issues that have united to address the national nursing shortage. ANSR
    stands ready to work with the Congress to advance programs and policy
    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 $267.3 million in funding in fiscal year 2011 for the
            Nursing Workforce Development Programs under title VIII of the
            Public Health Service Act at the Health Resources and Services
            Administration (HRSA).
      --Direct the requested increase at the title VIII programs that have
            not kept pace with inflation since fiscal year 2005: Advanced
            Education Nursing, Nursing Workforce Diversity, Nurse
            Education, Practice and Retention, and Comprehensive Geriatric
            Education. These programs, which help expand nursing school
            capacity and increase patient access to care, would greatly
            benefit from the 10 percent increase awarded in proportion to
            their fiscal year 2010 funding levels.
    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 3.733 million licensed RNs in 2008.\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. In 2008, 60 percent of
    RN jobs were in hospitals.\2\ About 8 percent of RN jobs were in
    physician offices, 5 percent in home healthcare services, 5 percent in
    nursing care facilities, and 3 percent in employment services. The
    remainder worked mostly in government agencies, social assistance
    agencies, and education services. A Federal report published in 2004
    estimates that by 2020 the national nurse shortage will increase to
    more than one 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,
    employment of registered nurses is expected to grow by 22 percent from
    2008 to 2018, much faster than the average for all occupations and,
    because the occupation is very large, 581,500 new jobs will result.
    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, (2010). 2008 Nurse
    Licensee Volume and NCLEX Examination Statistics. (Research Brief Vol.
    42). On the Internet at: https://www.ncsbn.org/
    10_2008NCLEXExamStats_Vol42_web_links.pdf (Accessed March 15, 2010).
        \2\ Bureau of Labor Statistics, U.S. Department of Labor.
    Occupational Outlook Handbook, 2010-11 Edition, Registered Nurses. On
    the Internet at: http://www.bls.gov/oco/ocos083.htm (Accessed February
    26, 2010).
        \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 February 26, 2010).
        \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
    now 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. The National League for Nursing found that in the 2007-2008
    academic year, 119,000 qualified applications--or 39 percent of all
    qualified applications submitted to nursing education programs--were
    denied due to lack of capacity. Baccalaureate degree programs turned
    away 24 percent of its applications, while associate degree programs
    turned away 42 percent.\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, (2010). Nursing Data Review 2007-
    2008: Baccalaureate, Associate Degree, and Diploma Programs. On the
    Internet at: http://www.nln.org/research/slides/index.htm. (Accessed
    February 26, 2010).
    ---------------------------------------------------------------------------
        The Alliance 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:  (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 because 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. 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.
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
    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 $267.3 million in
    funding for the Nursing Workforce Development Programs under Title VIII
    of the Public Health Service Act at HRSA in fiscal year 2011. The
    requested increase should be directed at the Title VIII programs that
    have not kept pace with inflation since fiscal year 2005: Advanced
    Education Nursing, Nursing Workforce Diversity, Nurse Education,
    Practice and Retention, and Comprehensive Geriatric Education. These
    programs, which help expand nursing school capacity and increase
    patient access to care, would greatly benefit from the 10 percent
    increase awarded in proportion to their fiscal year 2010 funding
    levels.

                           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
        Citizen Advocacy Center
        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 Hispanic Nurses
        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 Council of Women's Organizations
        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
        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
        Women's Research & Education Institute
        Wound, Ostomy and Continence Nurses Society
                                     ______

          Prepared Statement of the Association of Organ Procurement
                                 Organizations

        The Association of Organ Procurement Organizations (AOPO) supports
    additional funding for the Division of Transplantation. AOPO is the
    nonprofit, national organization that represents the Nation's 58
    federally designated organ donation agencies through advocacy, support,
    and program development that will maximize the availability of organs
    and tissues. AOPO seeks to enhance the quality, effectiveness, and
    integrity of the donation process. The Division of Transplantation's
    mission is to provide oversight and guidance to the donation and
    transplantation regulations and processes in the United States, and, in
    that role, it enhances the efforts of AOPO and other organizations
    working to increase the number of lives saved through transplantation,
    research, education, and therapy.
        The timeliness of this funding request is particularly urgent.
    Organ donation saves lives. Since transplantation is standard therapy
    for end-stage organ failure, donation is a vital component of end-of-
    life care in the United States. There are almost 107,000 people waiting
    for a transplant in the United States, 18 of whom will die today while
    waiting for the gift of life. That equates to approximately one person
    dying every 90 minutes, an entirely preventable public health crisis.
        In 2005, the Office of Management and Budget (OMB) set a Federal
    goal to increase the number of organs donated annually by deceased
    individuals in the United States to 35,000 by 2012. In 2009, more than
    24,000 organs were donated. As one of the catalysts in the donation
    process, organ procurement organizations (OPOs) must coordinate with
    all stakeholders to reach this Federal goal. OPOs provide community
    education and programs to medical professionals to help them
    participate and support the donation process in every hospital in the
    United States. The hospital turns to the OPO for support and expertise
    when a donation situation presents itself. By law, OPOs must meet
    strict Federal performance standards and operate within a regulated
    system under the Department of Health and Human Services.
        Increasing organ availability in the United States can be achieved
    through several simultaneous strategies: enrolling all willing donors
    in donor registries; improving how donation from deceased donors is
    handled in U.S. hospitals; and by encouraging and protecting those who
    wish to donate organs while they are still alive.
        Organ donation from deceased donors remains the most important
    source of increasing organ availability. Today, donation occurs in
    approximately 68 percent of eligible cases. This is up from 50 percent
    in 2003. OPOs now recover more than 3 organs per deceased individual.
    More increases can be achieved if the government and organ donation and
    transplantation professionals act on the changing nature of the organ
    donor pool. The increases in the incidence of obesity, diabetes and
    hypertension that affect the general public affect organ donors as
    well. It takes more resources to evaluate medically complex donation
    cases and it takes longer for recipients to recover from
    transplantation when these organs are received. Outdated Federal
    regulations fail to account for this new donation and transplantation
    reality, and do not go far enough to safeguard the potential supply of
    organs and tissues from possible unintended consequences. Performance
    outcome measures for transplant hospitals and OPOs must be risk-
    adjusted to account for the use of these donors with potentially
    compromising medical conditions. OPOs are already reimbursed on a cost-
    basis. Any reduction in payment would cause recovery costs to fall
    below the actual costs of procuring organs. Increased funding is
    critical to ensure that organ and tissue recovery does not decrease as
    a result of inadvertent consequences. New healthcare reform measures
    should not affect reimbursement policies by penalizing hospitals for
    potentially longer inpatient stays to manage transplant recipients with
    challenged donor organs because transplanting these organs is the
    optimal outcome for these patients.
        Current OPO success measures are based on organs transplanted per
    donor and categorized by the type of donor. Preliminary work shows
    promise with a more objective and replicable evaluation system for
    OPOs. With additional funding, new tools can be developed that
    strengthen performance-based metrics and expand organ donation
    potential. To accomplish these goals, it is necessary for HHS officials
    and representatives of HRSA and CMS to partner with the donation and
    transplantation community to create a regulatory and reimbursement
    environment that fosters achievement of national performance goals.
        The President's fiscal year 2011 budget allocates $4 million for
    Breakthrough Collaboratives on Organ Donation and Transplantation,
    initiatives that encourage teams of organ procurement, transplantation
    and critical care professionals to improve the organ donation and
    transplantation process in their local areas. OPOs must have the
    ability to identify, recruit, train, and financially support the
    involvement of critical care professionals (e.g., physicians, nurses,
    respiratory therapists) in local, regional, and national efforts to
    optimize donor organ function prior to donation. Best practices are
    shared for replication on a local level. More funding can and should be
    provided to ensure that healthcare professionals are properly trained
    to partner with OPO professionals to lead the donation process in their
    hospitals. We recommend that funding for the Collaboratives be
    increased from $4 million to $6 million to strengthen this national
    learning program.
        The extra $2 million appropriated to the Division of
    Transplantation in fiscal year 2010 was allocated to the OPTN (Organ
    Procurement and Transplantation Network) to develop strategies to
    increase living donation and establish a greater number of paired
    kidney programs. Although living donation is one way to increase the
    supply of scarce resources, and the $2 million will make a positive
    impact, our country currently lacks the infrastructure to take full
    advantage of this donation option. Barriers to living donation remain.
    For example, there is no national living donor registry. Even more
    concerning, insurance companies can include living donation as a pre-
    existing condition. Legislation to include prohibiting living organ
    donation as a pre-existing condition for health insurance exclusions
    was introduced more than a year ago in both the House (H.R. 1558) and
    Senate (S. 623). Last June, a bill was introduced that would amend the
    Family and Medical Leave Act of 1993 to allow non-Federal employees up
    to 12 weeks of unpaid, job-protected leave in a 12-month period to
    provide living donation. Other methods to encourage living donation,
    such as the Living Organ Donor Tax Credit Act of 2009 (H.R. 218), have
    been proposed to allow incentives to encourage organ donation. Though
    this bill is stalled, it would allow a nonrefundable tax credit of up
    to $5,000 for unreimbursed costs and lost wages related to living
    donation. No action has been taken on any of these bills. Until this is
    done, it could be unwise to encourage more organ donation from living
    individuals.
        OPOs and other agencies, such as Donate Life America, have tried to
    counterbalance the rising waiting list numbers by increasing the number
    of Americans who are registered organ and tissue donors. At the end of
    2009, donor registrants in state registries topped 86.3 million. Donate
    Life America has just released a survey in early 2010 showing that 57
    percent of U.S. adults support organ donation, a 7 percent increase
    from a 2009 survey. While 57 percent of Americans would sign up, only
    37.1 percent have actually done so, indicating many do not know how to
    do so.
        Representative Clay from Missouri proposed a bill (H.R. 3071) which
    authorized successful grants for the development, enhancement,
    expansion, and evaluation of State organ and tissue donor registries to
    aid in this effort to expand the donor pool. In addition, AOPO has
    worked with States to strengthen donor designation laws through efforts
    such as a nationwide effort to pass the revised Uniform Anatomical Gift
    Act (UAGA) in every State, and through a proposed resolution to the
    National Association of Attorneys General (NAAG). Donor registries have
    proven successful, but to close this gap, funding for public and
    professional education programs focused on increasing donor
    registrations should be extended from $3.749 million to $6.2 million.
        Almost 107,000 people in the United States are waiting for
    lifesaving organ transplants, and every 11 minutes another name is
    added to the transplant waiting list. A million more suffer from
    conditions that could be successfully treated with donated corneas or
    tissue. The current system is not keeping pace with the critical
    shortage of vital organs in this country. Through additional funding
    for research, training and outreach, many more lives will be saved and
    improved.
        The Division of Transplantation represents less than 0.35 percent
    of HRSA's discretionary budget authority, but adequate funding to help
    reach the HRSA national performance goals could amount to millions of
    dollars in savings to the Medicare program as a result of patients
    being freed from the requirement of long-term dialysis. These are the
    additional increases to the fiscal year 2011 budget supported by AOPO:
      --Additional funding for the Division of Transplantation should be
            granted. In order to reach Federal goals, the pool of potential
            donors must be widened. OPOs are looking at numerous ways to
            increase organ donation. Some programs are taking advantage of
            extended criteria donors, while others are mastering other
            donation options such as donation after cardiac determination
            of death. In order to fully and safely explore these and other
            avenues to increase donation, funding for these and other
            programs must be specified. OPOs operate under strict
            governmental guidelines, which limit the amount of research and
            development OPOs can perform.
      --Studies about the effect of potential healthcare reform measures
            should be conducted to guarantee organ recovery is not
            negatively impacted. We recommend that the $500,000 to conduct
            a study to define organ donor potential in the United States be
            increased to $2 million.
      --HRSA has not altered the types of organ donation grants in several
            years. We recommend that funding for new grant projects to
            increase organ donation be given $10.2 million, up from $7.2
            million requested.
                                     ______

          Prepared Statement of the American Psychological Association

        The American Psychological Association (APA), in Washington, DC, is
    the largest scientific and professional organization representing
    psychology in the United States, including more than 150,000
    researchers, educators, clinicians, consultants, and students. APA
    works to advance psychology as a science, as a profession and as a
    means of promoting health, education and human welfare. Below are APA's
    recommendations for the funding of programs in the Departments of
    Health and Human Services, and Education for fiscal year 2011.
        APA supports the recommendations of the Ad Hoc Group for Medical
    Research Funding of $35 billion for the National Institutes of Health,
    and of the Coalition for Health Funding which supports an increase of
    $9.3 billion for all the agencies of the U.S. Public Health Service.
    The public health system requires additional support after years of
    underinvestment. We are concerned that our already fragile public
    health infrastructure lacks the capacity to support mounting health
    needs under the weight of an ongoing recession, an aging population, a
    health workforce shortage, and persisting declines in health status.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

        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 & Services Administration. This nationally competitive grant
    program provides integrated healthcare services to underserved rural
    and urban communities and individuals most in need of mental and
    behavioral health support with the least access to these services
    (e.g., children, older adults, chronically ill persons, victims of
    abuse or trauma, including veterans). To date there have been 70 grants
    in 30 States to universities and hospitals throughout the Nation. All
    psychology graduate students who benefited from GPE funds are expected
    to work with underserved populations and 34-100 percent will work in
    underserved areas immediately after completing the training.
        Currently it is 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.
    Explicit authorizing legislation was introduced in the First Session of
    the 111th Congress in the U.S. Senate (S. 811), as well as in the U.S.
    House of Representatives (H.R. 2066). The GPE Program has been included
    in the President's Budget for the past 2 years.
        Established in 2002, GPE grants have supported the
    interdisciplinary training of more than 2,500 graduate students of
    psychology and other health professions to provide integrated
    healthcare services to underserved populations. The fiscal year 2011
    GPE funding request will focus especially on providing services to
    older adults, returning veterans, and the unemployed. The GPE funding
    request will also be used to create training opportunities at our
    Nation's Federal Qualified Health Centers, which play a critical role
    in meeting the health and mental/behavioral healthcare needs of
    underserved communities all across the country.
        The GPE Program specifically seeks to address the needs of older
    adults. Approximately 20 percent of older adults have a mental health
    condition, such as depression, anxiety, alcohol, or substance abuse. In
    addition, studies show that substance abuse combined with depression
    makes older adults especially vulnerable to suicide (Retooling for an
    Aging America, IOM, 2008). Moreover, older adults with chronic
    illnesses such as heart disease have higher rates of depression than
    those who are physically healthy (APA, 2008). Rural areas have a
    greater percentage of older adults than urban areas, and older adults
    in rural communities have a higher incidence of chronic illnesses such
    as heart disease, diabetes, high blood pressure, and obesity than those
    in urban communities (Alliance for Health Reform, RWJ Foundation,
    January 2010).
        Because of their extensive education and training, psychologists
    are uniquely qualified to address the needs of unemployed persons
    (e.g., assessing skills and interests for retraining; determining the
    emotional status of the individual; treating mental and behavioral
    health issues; and providing guidance for job searches, interviewing
    strategies and techniques). The issue of joblessness and unemployment
    is a serious problem for many families, including those of returning
    veterans. Job loss due to multiple deployments has become a serious
    issue for this population, especially in the current economy.
        Center for Mental Health Services, Minority Fellowship Program.--
    MFP's mission is to increase the number of minority mental health
    professionals and by training mental health professionals to become
    culturally competent. APA urges Congress to fund Minority Fellowship
    Program at $7.5 million for fiscal year 2011. APA does not recommend
    that SAMHSA include additional organizations in the program if it would
    mean reductions in funding for current grantees.
        Center for Substance Abuse Prevention, Substance Use and Mental
    Disorders of Persons with HIV.--HIV-positive individuals who have co-
    occurring mental health and substance use disorders rarely receive
    ``integrated'' care with a treatment plan for all three disorders. APA
    recommends that Congress urge HRSA and SAMHSA to collaborate to expand
    the availability of the integrated care model. An integrated approach
    to HIV/AIDS care, mental health support and substance abuse treatment
    can improve patient adherence and lead to more favorable health
    outcomes for people living with HIV/AIDS.
        Emergency Mental Health and Traumatic Stress Services Branch, Child
    Trauma.--APA urges full funding for the National Child Traumatic Stress
    Initiative at the authorized level of $50 million for fiscal year 2011.
    Also, APA recommends the Committee to encourage SAMHSA to expand the
    duration of NCTSI grant awards from 3 years to 6 years.
        Centers for Disease Control and Prevention, National Center for
    Health Statistics, Sexual and Gender Identity Inclusion in Health Data
    Collection.--APA recommends the allocation of an additional $2 million
    in funding for NHIS in the NCHS budget, to cover the cost of adding a
    sexual orientation/gender identity question to the survey. This would
    enable government agencies to better understand and plan for the unique
    health needs of lesbian, gay, bisexual, and transgender individuals.
        CDC, National Center for Injury Prevention and Control, Youth
    Violence Prevention.--APA supports CDC's efforts to foster innovation
    in evidence-based youth violence prevention strategies through its
    Striving to Reduce Youth Violence Everywhere program. Recent, high-
    profile incidents have highlighted youth violence as a significant
    public health concern and homicide as the second leading cause of death
    among individuals age 10-24.
        Community Health Centers (CHCs), Child Maltreatment Prevention.--
    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. APA also supports education, recruitment, and training of
    mental health and primary care providers to implement culturally
    informed preventative programs that enhance parenting practices and
    screenings at the centers.
        Administration for Children and Families, Healthy Media for
    Youth.--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.
        Strengthening Families.--APA encourages ACF to continue its support
    of research programs that aim to strengthen families with economic
    hardship using empirically supported skills-based approaches. These
    projects aim to teach proven family strengthening skills and principles
    such as relationship education, stress management, and child-centered
    parenting to promote healthy inter-parental relationships that lead to
    healthy, well-functioning children.
        National Institutes of Health (NIH), behavioral research.--
    Understanding the complex influences of behavior on health is a
    critical part of NIH's mission. There is strong evidence that half of
    all deaths in the United States can be attributed to behavioral factors
    such as smoking, poor diet, substance abuse, and physical inactivity.
    In addition, behavioral and social factors contribute to the staggering
    costs of preventable morbidity and mortality. NIH-supported behavioral
    and social sciences research ranges from basic research on memory,
    learning and perception, to prevention research, to clinical trials and
    comparative effectiveness research.
        NIH, Office of Behavioral and Social Sciences Research.--OBSSR was
    authorized by Congress in the NIH Revitalization Act of 1993 and
    established in 1995. For fiscal year 2011, APA supports a budget of
    $41.32 million for OBSSR to fulfill its coordinating role, commensurate
    with the administration's request of $38.2 million for the Office and
    the scientific community's request for the NIH as a whole.
        NIH, Office of Behavioral and Social Sciences Research, Basic
    Behavioral and Social Sciences Research.--APA is pleased that NIH has
    established a initiative to increase and coordinate trans-NIH support
    for basic behavioral and social sciences research. Coordinated by OBSSR
    with leadership and contributions from multiple NIH institutes, the
    Opportunity Network for Basic Behavioral and Social Sciences Research
    (OppNet), will fund basic research to help fill gaps in knowledge about
    fundamental mechanisms and patterns of behavioral and social
    functioning, relevant to health and well-being, as they interact with
    each other, with biology and the environment.
        NIH, National Institute on Minority Health and Health Disparities,
    Health Disparities.--The recent healthcare reform legislation elevated
    the National Center on Minority Health and Health Disparities within
    NIH, giving it greater authority to address the health disparities that
    exist in minority communities. APA recommends that Congress provide
    sufficient funding for NIMHD to carry out its mandated functions, and
    urges Congress to support NIMHD in its enhanced role to address
    priority health conditions of minority populations.
        NIH, Behavioral Research Highlights.--The following areas of NIH-
    supported research are good examples of the breadth and vitality of the
    behavioral research portfolio at NIH:
        NIH Roadmap, Science of Behavior Change.--By focusing basic
    research on the initiation, personalization, and maintenance of
    behavior change, and by integrating work across disciplines, this
    Roadmap effort and subsequent trans-NIH activity could lead to an
    improved understanding of the underlying principles of behavior change,
    and drive a transformative increase in the efficacy, effectiveness, and
    (cost) efficiency of many behavioral interventions.
        NIMH, Children's Mental Health.--Early diagnosis, prevention and
    treatment is critical for the millions of families affected by autism,
    attention deficit hyperactivity disorder, anxiety disorders,
    depression, bipolar disorder, and eating disorders. NIMH is supporting
    important clinical trials to demonstrate the evidence base for
    effective pharmacological and behavioral interventions treatments for
    child and adolescent populations with these disorders.
        NIDA, Tobacco Addiction.--While significant declines in smoking
    have been achieved in recent decades, too many Americans, particularly
    youth, remain addicted to tobacco products. NIDA-supported researchers
    are identifying genetic and environmental factors that contribute to
    nicotine dependence and affect the efficacy of smoking cessation
    treatments.

                            DEPARTMENT OF EDUCATION

        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, including sponsoring studies that will demonstrate the
    impact of socio-emotional, behavioral and attitudinal aspects of
    disability. APA encourages initiatives that support a broad field of
    NIDRR research, including Health and Functioning, Community Integration
    and Employment which will address societal barriers, such as
    stigmatization and discrimination, and their impact on people with
    physical, mental and neurological disabilities.
                                     ______

     Prepared Statement of the Association for Professionals in Infection
                            Control and Epidemiology

        The Association for Professionals in Infection Control and
    Epidemiology (APIC) thanks you for this opportunity to submit testimony
    and greatly appreciates this subcommittee's leadership in providing the
    necessary funding for the Federal Government to have a leadership role
    in the effort to eliminate healthcare-associated infections (HAIs).
        APIC's mission is to improve health and patient safety by reducing
    the risk of healthcare-associated infections and related adverse
    outcomes. The organization's more than 13,000 members, known as
    infection preventionists, direct infection prevention programs that
    save lives and improve the bottom line for hospitals and other
    healthcare facilities throughout the United States and around the
    globe. Our association strives to promote a culture within healthcare
    institutions where all members of the healthcare team fully embrace the
    elimination of HAIs. We advance these efforts through education,
    research, collaboration, practice guidance, public policy, and
    credentialing.
        HAIs are among the leading causes of preventable death in the
    United States, accounting for an estimated 1.7 million infections and
    99,000 associated deaths in 2002. In addition to the substantial human
    suffering caused by HAIs, these infections contribute $28 billion to
    $33 billion in excess healthcare costs each year.
        We are greatly appreciative of funding provided in the fiscal year
    2010 Consolidated Appropriations Act to resource HAI reduction efforts.
    In particular, we support the $5 million appropriation for the HHS
    Office of the Secretary to coordinate and integrate HAI-related
    activities across the Department, $136 million for the Centers for
    Disease Control and Prevention's (CDC) emerging infectious diseases
    portfolio for expanded surveillance, public health research and
    prevention activities, $15 million to expand the CDC National
    Healthcare Safety Network (NHSN) and finally, $34 million for the
    Agency for Healthcare Research and Quality's (AHRQ) MRSA Collaborative
    Research Initiative and for implementing evidence-based HAI prevention
    training nationwide.
        In fiscal year 2011, we ask that you support the CDC Coalition's
    $8.8 billion for CDC's ``core programs.'' CDC serves as the command
    center for our Nation's public health defense system against emerging
    and re-emerging infectious diseases. From pandemic flu preparedness and
    prevention activities to West Nile virus to smallpox to SARS, the
    Centers for Disease Control and Prevention is the Nation's--and the
    world's--expert resource and response center, coordinating
    communications and action and serving as the laboratory reference
    center. APIC members rely on CDC for accurate information and direction
    in a crisis or outbreak. We ask that you provide $2.3 billion for the
    CDC's Infectious Diseases programs.
        Because our members are on the front line in healthcare facilities,
    bringing their expertise in infection prevention to the patient's
    bedside, there are so many areas within the CDC budget that we could
    highlight. Allow us to outline some of the areas of greatest concern to
    our membership. We support the administration's fiscal year 2011
    request for $27 million to expand NHSN to approximately 2,500 new
    hospitals. Currently, 21 States require hospitals to report HAIs using
    NHSN. However, CDC supports more than 2,300 participating hospitals in
    NHSN in all 50 States. This surveillance system plays an important role
    in improving patient safety at the local and Federal levels. NHSN's
    data analysis function helps our members analyze facility-specific data
    and compare rates to national aggregate metrics. It also allows CDC to
    estimate and characterize the current burden of HAIs in the United
    States. Every step taken to create interoperable data systems in which
    our members can input HAI data and have it go directly to NHSN is a
    step toward freeing our members to do more hands-on infection
    prevention activities.
        We also appreciate the administration's proposal of $155.9 million
    for emerging infectious diseases in fiscal year 2011 and ask that you
    increase funding for this purpose to $200 million to allow CDC to work
    with partners at the State and local level to detect and respond to
    this important public health threat.
        In addition, we support the $10 million budget request for the new
    Health Prevention Corps. We appreciate the importance of targeting
    disciplines with existing shortages with a workforce program designed
    to recruit talented new individuals for State and local health
    departments.
        APIC is concerned, that the administration's proposed budget would
    cut the Antimicrobial Resistance budget by $8.6 million, just more than
    50 percent. We agree with the agency's congressional justification that
    this is ``one of the world's most pressing public health problems'' and
    ask that you increase funding for CDC antimicrobial resistance
    activities in fiscal year 2011 to $40 million.
        In addition, we support the $34 million in the administration's
    fiscal year 2011 budget to build upon AHRQ efforts--now in all 50
    States, the District of Columbia and Puerto Rico--to reduce bloodstream
    infections in intensive care units (ICUs) through implementation of a
    safety compliance checklist and providing staff with evidence-based
    practices. We support these efforts and AHRQ's plans to reach out to
    the CDC to identify and design projects to reduce the incidence of HAIs
    in other infection sites using evidence-based practices.
        Further, APIC supports the administration's request to build upon
    American Recovery and Reinvestment Act (ARRA) efforts by supporting use
    of the HAI survey tool developed jointly by CDC and the Centers for
    Medicare and Medicaid Services (CMS) with ARRA funds. The
    administration's fiscal year 2011 request under Survey and
    Certification would increase survey frequencies at ambulatory surgery
    centers (ASCs) to every 4 years. Due to the increasing number of
    surgeries performed in outpatient settings, and the need to ensure that
    basic infection prevention practices are followed, APIC supports
    efforts to increase the use of this survey tool.
        Finally, we support the administration's $5 million request for HAI
    activities to support continued efforts of the HHS Action Plan to
    Prevent Healthcare-Associated Infections (HAI Action Plan). This
    funding will allow HHS to continue current efforts and expand upon a
    national media campaign, utilize social media tools, develop a single
    comprehensive Web site for HAI information, and evaluate the media
    campaign and original Action Plan and assess whether it is achieving
    its intended goals.
        We believe the development of the HAI Action Plan and the funding
    to support these activities has been an essential tool in the effort to
    build support for a coordinated Federal message on preventing
    infections. Additionally, we feel very strongly that the CDC has the
    necessary expertise to define appropriate metrics through which the HAI
    Action Plan can best measure its efforts.
        APIC strongly believes that to move toward our goal of HAI
    elimination, there needs to be a concerted effort to fund research into
    the knowledge gaps outlined in the HAI Action Plan, with an eye toward
    the science of implementation.
        This subcommittee has taken essential steps in using stimulus funds
    to build the necessary infrastructure within States to address HAI
    reduction. Your leadership has also put resources into improving
    surveillance efforts and scaling-up proven HAI prevention approaches.
    However, while resources have encouraged States to plan for HAI
    prevention efforts, APIC's 2009 Economic Survey of our membership
    indicates that infection prevention budgets within healthcare
    facilities have been hard hit, particularly in the area of education.
        Three-quarters of our members who reported that their budgets were
    cut in our recent survey have experienced decreases for the education
    that trains healthcare workers in preventing HAI transmission. Half saw
    reductions in overall budgets for infection prevention, including money
    for technology, staff, education, products equipment and updated
    resources. Nearly 40 percent had layoffs or reduced hours. While we
    fully support your effort to put infrastructure in place in States to
    promote HAI reduction efforts and believe that was a very wise use of
    one-time stimulus funding, we need to make clear that our membership
    would be hard-pressed to scale up HAI reduction efforts while their
    budgets are facing these kinds of decreases.
        We thank you for the opportunity to submit testimony and greatly
    appreciate this subcommittee's leadership in providing the necessary
    funding for the Federal government to have a leadership role in the
    effort to eliminate HAIs.
                                     ______

          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 2011.
        APPA has consistently supported an increase in the authorization
    level for LIHEAP. The administration's fiscal year 2011 budget requests
    $3.3 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 2011.
                                     ______

            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). Research carried out by the NIH contributes
    to our understanding of health and disease, which allows all Americans
    to look forward to a healthier future. In this testimony, APS
    recommends that the NIH be funded at $37 billion in fiscal year 2011.
        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.
    Momentum From the American Recovery and Reinvestment Act (ARRA) Should
            be Maintained at NIH
        The inclusion of $10.4 billion for biomedical research in ARRA has
    provided the NIH with an unprecedented opportunity to move science
    forward. To date, the ARRA investment has funded more than 14,000
    scientific projects in all 50 States.\1\
    ---------------------------------------------------------------------------
        \1\ http://report.nih.gov/recovery/arragrants.cfm
    ---------------------------------------------------------------------------
        Last year the NIH moved quickly to take advantage of the
    opportunities provided by ARRA to address important areas of scientific
    need. ARRA funds are already being used to support new science in high-
    priority areas such as biomarker discovery, regenerative medicine, stem
    cell research and translational science through the Challenge Grant
    program. ARRA funds are also being used to support highly meritorious
    research proposals that had gone unfunded due to years of slow growth
    in the NIH budget. In recent years, only 1 out of every 5 proposals
    submitted to the NIH received funding, leaving many important research
    questions unexplored. The ARRA funds have allowed NIH to direct funds
    to some of the most interesting and important projects that were
    unfunded for budgetary reasons. ARRA funds will also reach the next
    generation of scientists through hands-on summer research experiences
    for approximately 5,000 undergraduates and science educators.
        As a result of the ARRA investment, the NIH estimates that 50,000
    jobs nationwide will be created or retained.\2\ The widespread
    distribution of NIH ARRA funds has already had a direct economic impact
    on the research community by funding labs and projects that would
    otherwise have gone unfunded. However, State and local economies also
    stand to benefit substantially from the stimulus funds being spent by
    NIH researchers. A report by Families USA showed that on average in the
    year 2007, every $1 of NIH funding generated twice as much in State
    economic output.\3\
    ---------------------------------------------------------------------------
        \2\ http://report.nih.gov/PDF/
    Preliminary_NIH_ARRA_FY2009_Funding.pdf
        \3\ http://www.familiesusa.org/assets/pdfs/global-health/in-your-
    own-backyard.pdf
    ---------------------------------------------------------------------------
        In order to capitalize and build on the functional capacity created
    through the ARRA investment, we urge Congress to make every effort to
    fund the NIH at a level of $37 billion in fiscal year 2011. Funding at
    this level takes into account the additional ARRA funds that have been
    added to the NIH budget, and allows for growth at the rate of the
    biomedical research and development price index (BRDPI). This will
    maintain the momentum created by ARRA and start the NIH on a new path
    of consistent and sustainable growth in future budget cycles.
    NIH Funds Outstanding Science
        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 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 results in new tools and
    knowledge that can be used to design novel treatments and prevention
    strategies. A key example comes from the recent outbreak of H1N1 flu.
    From the time that the first cases of the disease emerged, it took
    approximately 6 months to develop a vaccine, identify those most at
    risk and begin to understand how and why the H1N1 flu strain differs
    from those seen in an average year. The ability to rapidly respond to
    this and other threats to human health is directly dependent upon
    maintaining a robust scientific enterprise.
        Last year the Nobel Prize in Physiology or Medicine was awarded to
    three longtime NIH grantees. Drs. Jack Szostak, Elizabeth Blackburn and
    Carol Greider shared the 2009 prize for their discovery of how the tips
    of chromosomes are protected from degradation during cell division.
    Since the discovery of this fundamental cellular mechanism, researchers
    have been able to apply this knowledge to better understand how cells
    age and why they sometimes become cancerous. Collectively NIH has
    supported their research for more than 30 years.\4\ Three other NIH
    grantees won the Nobel Prize in Chemistry in 2009. Drs. Venkatraman
    Ramakrishnan, Thomas A. Steitz and Ada E. Yonath identified the
    structure of the ribosome, the molecular machinery that makes proteins
    in cells. NIH has supported these researchers in their work for nearly
    four decades.\5\
    ---------------------------------------------------------------------------
        \4\ http://www.nigms.nih.gov/News/Results/nobel20091005.htm
        \5\ http://www.nigms.nih.gov/News/Results/nobel_20091007a.htm
    ---------------------------------------------------------------------------
    NIH Nurtures the Biomedical Research Enterprise
        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. The administration's
    fiscal year 2011 budget proposal includes funding for a 6 percent
    increase in stipend levels for National Research Service Awards. The
    APS applauds this proposed increase and calls on Congress to make every
    effort to fully fund the request.
        New investigators entering the scientific workforce have frequently
    encountered long training periods before gaining independence and
    funding for their own research labs. In fiscal year 2007, the average
    age of new investigators receiving their first awards from NIH rose to
    42 years. To address this problem and foster the next generation of
    scientists, the NIH has committed to funding new investigators at
    approximately the same rate as established investigators.\6\ This will
    allow investigators to become independent and able to explore
    innovative ideas at an earlier stage of their careers. 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.
    ---------------------------------------------------------------------------
        \6\ http://grants.nih.gov/grants/new_investigators/index.htm
    ---------------------------------------------------------------------------
        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.
        The APS joins the Federation of American Societies for Experimental
    Biology in urging that NIH be provided with $37 billion in fiscal year
    2011 so that researchers can build on the momentum and capacity created
    through the ARRA investment.
                                     ______

        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 $35 billion for
    the National Institutes of Health (NIH) in fiscal year 2011.
        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 sustains
    its cross-NIH basic behavioral research funding initiative, the Basic
    Behavioral and Social Science Opportunity Network (OppNet), 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 2011
    appropriations for 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 22,000
    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
    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 $35 billion for NIH in fiscal year 2011, an increase of 12.6
    percent more than the fiscal year 2010 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.
    NIH's New Commitment to Basic Behavioral Science Research Should Be
            Made Permanent
        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. Thanks
    in large part to the leadership of this Committee and your counterparts
    in the House, NIH has launched a new initiative that supports and
    expands new basic behavioral research throughout NIH. In November 2009,
    NIH leadership launched the Basic Behavioral and Social Science
    Opportunity Network (OppNet), and has already released several funding
    opportunities. OppNet is currently organizing its strategic plan to
    prioritize research areas it will fund over the next 4 years. This plan
    should include, at the very least, the following areas of research that
    will be critical to its success and more importantly, critical for the
    NIH to best take advantage of what this field has to offer:
      --identifying the dimensions of the environment that create,
            moderate, and reverse risks for mental and physical health
            disorders;
      --a rigorous understanding of emotions, their regulation, and
            functions;
      --development of multiple methods of behavioral measurement;
      --the role of emotions and environmental factors in behavior change;
      --animal models of behavior that enrich our understanding of human
            processes;
      --interpersonal interactions across the lifespan and across social,
            economic, and cultural contexts; and
      --individual processes underlying personality, self, and identity.
        While we are greatly encouraged by the launch of OppNet, it is
    slated to end in 2014. That, combined with the lack of a permanent
    organizational structure for basic behavioral research at NIH, creates
    enormous uncertainty for an enterprise that by nature inherently
    requires a longer-term, stable commitment.
        APS respectfully asks the subcommittee to:
      --ensure that NIH adequately supports and sustains a strong,
            permanent program of basic behavioral science research and
            training as a critical element in improving the health and
            welfare of all Americans; and
      --ensure that behavioral research is a priority at NIH both by
            providing maximum funding for those institutes where behavioral
            science is a core activity and encouraging NIH to advance a
            model of health that includes behavior in its scientific
            priorities.
    Psychological Clinical Science Training and Public Health
        One in 4 adults and 1 in 5 children in the United States have a
    diagnosable mental disorder that impairs normal functioning, and mental
    illness accounts for more than 15 percent of the burden of disease in
    major nations; the economic burden associated with mental illness
    exceeds that of all forms of cancer combined. The costs associated with
    mental illness are staggering; $69 billion was spent on mental health
    services in the United States alone in 1996. This is more than 7
    percent of our total health spending. For these reasons, it is critical
    that our understanding of, diagnosis, treatment, and prevention of
    mental illness reflects the very best and most modern science possible.
        Unfortunately, the vast majority of clinical psychologists are
    currently being trained outside of the major research universities and
    hospitals. Even in the best of these training programs, students
    receive little or no direct contact with cutting-edge research. In many
    of these programs there is even an anti-science bias; students in these
    programs are being trained to diagnose and treat mental illness using
    methods that have no scientific support or, even worse, that have been
    shown to be of little or no value. To combat this problem, a group of
    the top 50 clinical psychology programs in the United States formed the
    Academy for Psychological Clinical Science, an organization committed
    to reaffirming the critical importance of science in clinical
    psychology training. The Academy recently established an independent
    accreditation system to insure that clinical psychology training
    programs meet the highest scientific standards, which will be critical
    for re-establishing the scientific foundation of clinical psychology.
        Individuals with mental illness and their families will know that
    practitioners who graduate from these programs will be delivering
    treatments that incorporate state-of-the-art scientific advances and
    that have passed the most critical scientific tests of their efficacy.
    Those communities and organizations wishing to provide state-of-the-
    art, scientifically based mental health services will know where to
    seek consultation and find the very best personnel. And finally, this
    new accreditation system will increase the supply of highly skilled
    scientists who will continue to fight the good fight again the ravages
    of mental illness.
        The National Institute of Mental Health's (NIMH) mission includes
    the assurance that that the science-based interventions its researchers
    generate can be used by patients, families, healthcare providers, and
    the wider community involved in mental healthcare. Most of the
    institutions that will be accredited under the new system (called the
    Psychological Clinical Science Accreditation System) include NIMH-
    funded researchers, and NIMH has already begun to support the new
    system in the spirit of advancing scientifically-sound treatments that
    its research helped develop. APS asks the Committee to support the new
    accreditation system for psychological clinical science training
    programs in order to reduce the burden of mental illness on
    individuals, families, communities, and society, through the use of
    empirically validated treatments by qualified practitioners.

                      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 is at the forefront of
    supporting behavioral science in the spirit of advancing the Nation's
    effort to prevent cancer. The Behavioral Research Program continues to
    invest in research on the development and dissemination of
    interventions in areas such as tobacco use, dietary behavior, sun
    protection, and decisionmaking. For example, knowledge about basic
    psychological mechanisms can be brought to bear on warnings about risky
    behavior, with a particular focus on tobacco use. The recently enacted
    FDA regulation of tobacco products is a landmark opportunity for
    tobacco control, and it presents a complimentary invitation for
    psychological science to revolutionize the study of warning labels and
    risky behavior. Specifically, recent research on graphic warning labels
    for cigarettes indicates that specific types of images can improve
    understanding of the consequences of smoking, and encourage motivations
    to quit smoking. APS asks the subcommittee to support NCI's behavioral
    science research and training initiatives and to encourage other
    Institutes to use them 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, older individuals face important and often complex
    decisions about retirement and other financial matters, and the normal
    aging process alters many of the psychological capacities and neural
    systems that come into play when making these decisions. Researchers
    are now looking at how healthy aging influences the psychological and
    neural bases of economic choice, and hope to speed along the
    development of interventions that remediate problems with
    decisionmaking in the elderly, resulting in public health benefits.
    NIA's commitment to cutting-edge behavioral science is further
    illustrated by the Institute's leadership role in NIH's new Common Fund
    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 Americans across the lifespan.
        Eunice Kennedy Shriver National Institute for Child Health and
    Human Development (NICHD).--NICHD is to be commended for supporting a
    broad spectrum of behavioral research, particularly as it relates to
    real-world problems. Let me give you one example, centering on the
    effects of socioeconomic adversity on children's brain development.
    Researchers are beginning to clarify the relationship among
    socioeconomic status (SES), early life experience, and learning in
    adolescents. We know that learning ability is positively correlated
    with SES, and recent research suggests that the effects of childhood
    experience on the development of certain parts of the brain may
    partially explain this. Researchers at the University of Pennsylvania
    are now learning about the nature and causes of the SES disparity in
    learning ability by examining its scope across different types of
    learning and different neural systems, and assessing its relation to
    early experience, including stress and parental nurturing. Thus, we are
    closer to understanding the crucial role played by learning in the
    academic, occupational, and personal lives of all Americans, and the
    prospect of preserving and fostering the learning ability in at-risk
    youth though the application of insights from the cognitive
    neuroscience of memory, stress, and early experience. APS asks the
    subcommittee 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.
        National Institute on Deafness and Other Communication Disorders
    (NIDCD).--NIDCD supports a vibrant and important portfolio of
    behavioral science research on voice, speech, and language. This
    research expands our understanding of the role of each hemisphere of
    the brain in communication and language, of early specialization of the
    brain, and of the recovery process following brain damage. Scientists
    are now exploring the genetic bases of child language disorders, as
    well as characterizing the linguistic and cognitive deficits in
    children and adults with language disorders. This and similar research
    programs are important because they offer valuable insight into the
    basis of the disorder and the associated academic problems encountered
    by many children with SLI. They are also likely to improve the
    classification, diagnosis, and treatment of other language, reading,
    and speech disorders. APS asks the subcommittee to support NIDCD's
    behavioral science research program and to increase NIDCD's budget in
    proportion to the overall increase at NIH in order to continue making
    significant advances in our understanding of and treatments for
    communication disorders in Americans of all ages.
        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
    Mental Health, the National Institute on Alcohol Abuse and Alcoholism,
    and the National Institute on Drug Abuse. 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 2011 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 Physical Therapy Association

        Chairman Harkin and Members of the Senate Subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies: On
    behalf of more than 74,000 physical therapists, physical therapist
    assistants, and students of physical therapy, the American Physical
    Therapy Association (APTA) thanks you for the opportunity to submit
    official testimony regarding recommendations for the fiscal year 2011
    appropriations. APTA's mission is to improve the health and quality of
    life of individuals in society by advancing physical therapist
    practice, education, and research. Physical therapists across the
    country utilize a wide variety of Federally funded resources to work
    collaboratively toward the advancement of these goals. APTA's
    recommendations for Federal funding as outlined in this document
    reflect the commitment toward these priorities for the good of society
    and the rehabilitation community.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

    National Institutes of Health (NIH)
        Rehabilitation research was funded at $404 million within NIH's
    approximately $30.5 billion budget in fiscal year 2009. This represents
    roughly 1 percent of NIH funds for an area of biomedical research that
    impacts a growing percentage of our Nation's seniors, persons with
    disabilities, young persons with chronic disease or traumatic injuries,
    and children with development disabilities. The Institute of Medicine
    estimates that 1 in 7 individuals have an impairment or limitation that
    significantly limits their ability to perform activities of daily
    living. Investment in and recognition of rehabilitation within NIH is a
    necessary step toward continuing to meet the needs of these individuals
    in our population. Through the American Recovery and Reinvestment Act
    (ARRA), rehabilitation research has been able to take advantage of an
    extra infusion of approximately $75 million in fiscal year 2009.
    However, APTA believes that rehabilitation research at NIH has been
    underfunded for many years. The funds currently utilized are well-
    invested for the impact that rehabilitation interventions will have on
    the quality of lives of individuals. Continued investment and greater
    recognition and coordination of rehabilitation research among
    Institutes and across Federal Departments will enhance the returns the
    Federal Government receives when investing in this area. Taking this
    into consideration, APTA advocates for $35.2 billion (a $4.2 billion
    increase more than fiscal year 2010) for NIH to capitalize on the
    momentum achieved under the ARRA investment to improve health, spur
    economic growth and innovation, and advance science.
        Specifically, the physical therapy and rehabilitation science
    community recommends that Congress allocate crucial funding
    enhancements in the following Institutes:
      --$1.5 billion (a 12.5 percent increase more than fiscal year 2010)
            for the Eunice Kennedy Shriver National Institute of Child
            Health and Human Development which houses the National Center
            for Medical Rehabilitation Research (NCMRR), the only entity
            within NIH explicitly focused on the advancement of
            rehabilitation science. NCMRR fosters the development of
            scientific knowledge needed to enhance the health,
            productivity, independence, and quality-of-life of people with
            disabilities. A primary goal of the Center-supported research
            is to bring the health-related problems of people with
            disabilities to the attention of the best scientists in order
            to capitalize upon the myriad advances occurring in the
            biological, behavioral, and engineering sciences.
      --$1.857 billion ($221 million increase more than fiscal year 2010)
            for the National Institute of Neurological Disorders and
            Stroke. This funding level is required to enhance existing
            initiatives and invest in new and promising research to prevent
            stroke and advance rehabilitation in stroke treatment. Despite
            being a major cause of disability and the number three cause of
            death in the United States, NIH invests only 1 percent of its
            budget on stroke research. However, APTA recognizes the
            advancements that NIH-funded research has achieved in the
            specific area of stroke rehabilitation. APTA commends this area
            of leadership at NIH and encourages a continued focus on
            rehabilitation interventions and physical therapy to maximize
            an individual's function and quality of life after a stroke.
      --$500 million in arthritis and musculoskeletal research within the
            National Institute of Arthritis and Musculoskeletal and Skin
            Diseases
    Centers for Disease Control and Prevention (CDC)
        APTA was disappointed to see the cuts that have been proposed for
    CDC through the administration's fiscal year 2011 budget proposal. The
    potential contributions of CDC to the lives of countless individuals
    are limited only by the resources available for carrying out its vital
    mission. Our Nation and the world will continue to benefit from further
    improvement in public health and investment in scientific advancement
    and prevention. APTA recommends Congress provide at least $8.8 billion
    for CDC's fiscal year 2010 ``core programs'' in the fiscal year 2011
    Labor, Health and Human Services, and Education, and Related Agencies
    appropriations bill. This request reflects the support CDC will need to
    fulfill its core missions for fiscal year 2011. APTA strongly believes
    that the activities and programs supported by CDC are essential in
    protecting the health of the American people.
        Physical therapists play an integral role in the prevention,
    education, and assessment of the risk for falls. The CDC is currently
    only allocating $2 million per year to address the increasing
    prevalence of falls, a problem costing more than $19.2 billion a year.
    Among older adults, falls are the leading cause of injury deaths. This
    is why APTA respectfully requests that $20.7 million be provided in
    funding for the ``Unintentional Injury Prevention'' account to allow
    CDC's National Center for Injury Prevention and Control to
    comprehensively address the large-scale growth of older adult falls.
        Currently, CDC's program on arthritis receives $13 million in
    annual funding, and about half of which is distributed via competitive
    grants to 12 States to deliver and promote proven arthritis
    intervention strategies. Physical therapy interventions are designed to
    restore, maintain, and promote maximal physical function for people
    with arthritis. An additional investment of $10 million, beginning in
    fiscal year 2011, would fund up to 14 new States and bring evidence-
    based prevention programs to many more Americans through innovative
    delivery approaches.
        Traumatic Brain Injury (TBI) is a leading cause of death and
    disability among young Americans and continues to be the signature
    injury of the conflicts in Iraq and Afghanistan. CDC estimates that at
    least 5.3 million Americans, approximately 2 percent of the U.S.
    population, currently require lifelong assistance to perform activities
    of daily living as a result of TBI. High-quality, evidence-based
    rehabilitation for TBI is typically a long and intensive process. From
    the battlefield to the football field, American adults and youth
    continue to sustain TBIs at an alarming rate and funding is desperately
    needed for better diagnostics and evaluation, treatment guidelines,
    improved quality of care, education and awareness, referral services,
    State program services, and protection and advocacy for those less able
    to advocate for themselves. APTA recommends at least $10 million in
    fiscal year 2011 for CDC's TBI Registries and Surveillance, Brain
    Injury Acute Care Guidelines, Prevention, and National Public
    Education/Awareness programs.
        APTA would like to see $76 million ($20 million increase more than
    fiscal year 2010) for CDC's Heart Disease and Stroke Prevention Program
    in fiscal year 2011. CDC spends on average only 16 cents a person each
    year on heart disease and stroke prevention, despite the fact that
    heart disease, stroke, and other forms of cardiovascular disease remain
    our Nation's number one and most costly killer. A $20 million increase
    in funding will allow CDC to support the 9 States that receive no
    funding for the competitively awarded Heart Disease and Stroke
    Prevention Program, elevate more States to basic program
    implementation, and support the other funded States.
        CDC's Well-Integrated Screening and Evaluation for Women Across the
    Nation (WISEWOMAN) programs screens uninsured and under-insured low-
    income women ages 40 to 64 for heart disease and stroke risk and those
    with abnormal results receive counseling, education, referral and
    follow up. WISEWOMAN reached more than 84,000 women and provided more
    than 210,000 lifestyle intervention sessions from 2000 to mid-2008,
    while also identifying 7,647 new cases of high blood pressure, 7,928
    new cases of high cholesterol, and 1,140 new cases of diabetes. Among
    those WISEWOMAN participants who were re-screened 1 year later, average
    blood pressure and cholesterol levels had decreased considerably. APTA
    recommends $37 million ($16.3 million increase more than fiscal year
    2010) for CDC's WISEWOMAN Program in fiscal year 2011.
    Health Resources and Services Administration (HRSA)
        Through the successful passage of healthcare reform legislation, it
    becomes more important now than ever that America is able to supply an
    adequate and well-trained healthcare workforce to meet the demands of
    an expanded market of U.S. citizens that have health insurance
    coverage. APTA urges you to provide at least $9.15 billion for HRSA in
    fiscal year 2011. This amount reflects the minimum amount necessary for
    the agency to adequately meet the needs of the populations they serve.
    The relatively level funding HRSA has received over the past several
    years has undermined the ability of its successful programs to grow and
    be expanded to represent professions that shape the entire healthcare
    team, such as physical therapy. Any shortage areas of physical
    therapists and rehabilitation professionals may become more accentuated
    as the percentage of the U.S. population that has health coverage
    increases and demand rises. It is beneficial to undertake efforts to
    strengthen the healthcare workforce and delivery across the whole
    spectrum of an individual's care--from onset through rehabilitation.
    More resources are needed for HRSA to achieve its ultimate mission of
    ensuring access to culturally competent, quality health services;
    eliminating health disparities; and rebuilding the public health and
    healthcare infrastructure.
        In conjunction with the importance of funding TBI efforts within
    CDC, APTA also recommends $8 million for the HRSA Federal TBI State
    Grant Program and $4 million for the HRSA Federal TBI Protection &
    Advocacy (P&A) Systems Grant Program

                            DEPARTMENT OF EDUCATION

        In 2008, as part of the reauthorization of the Higher Education Act
    (Public Law 110-315), the Loan Forgiveness for Service in Areas of
    National Need (LFSANN) program was created. This program would provide
    a modest amount of loan forgiveness for a variety of education and
    healthcare professional groups, including physical therapists, upon a
    commitment to serve in targeted populations that were identified as
    areas of crucial importance and national need. However, the program has
    not been implemented because it has not received any funding. APTA
    commends the recent efforts of Congress to reform the higher education
    loan industry. The lowering of the limit on the income-based repayment
    plan for consolidated Federal Direct Loans will assist the burdensome
    payments for all higher education loan borrowers. However, this program
    still fails to meet the most important impact of LFSANN--channeling
    providers and professionals into areas where there are demonstrated
    shortages and high need, such as physical therapy care for veterans and
    children and adolescents. APTA strongly urges Congress to take action
    and provide $10 million in initial funding for this vital LFSANN
    program that will impact the healthcare and education services of those
    most in need.
    National Institute for Disability and Rehabilitation Research (NIDRR)
        NIDRR has been one of the longest standing agencies to focus on
    federally funded medical rehabilitation research. Rehabilitation
    research makes a difference in the lives of individuals with
    impairments, functional limitations, and disability. Advancements in
    rehabilitation research have led to greater quality of life for
    individuals who have spinal cord injuries, loss of limb, stroke and
    other orthopedic, neurological, and cardiopulmonary disorders.
    Investment in NIDRR is a necessary step toward continuing to meet the
    needs of individuals in our population who have chronic disease,
    developmental disabilities or traumatic injuries. Therefore, APTA
    recommends at least $20 million per year for NIDRR to support research
    and development, capacity building, and knowledge translation in
    health, rehabilitation, and function.
        APTA also requests $11 million for NIDRR's TBI Model Systems
    administered by the Department of Education. 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 brain
    injury. They are a key source of evidence-based medicine and
    rehabilitation care for this crucial and growing population.
    Interagency Committee on Disability Research (ICDR)
        APTA would like to see $1.5 million appropriated for the ICDR to
    support a research agenda-setting summit. The disability and
    rehabilitation research community feels that such a meeting would
    ultimately be beneficial to work cooperatively on strategies to
    leverage the Federal investments in disability and rehabilitation
    research across all respective agencies and facilitate the conducting
    of meaningful collaborative projects and initiatives, including
    capacity building and knowledge translation.

                                   CONCLUSION

        APTA looks forward to working with the subcommittee and the various
    agencies outlined above to advance the resources available for the
    rehabilitation needs of society.
                                     ______

    Prepared Statement of the Association of Public Television Stations and
                          Public Broadcasting Service

        On behalf of America's 361 public television stations, we
    appreciate the opportunity to submit testimony for the record on the
    importance of Federal funding for local public television stations.
    Corporation for Public Broadcasting--Fiscal Year 2013 Request: $604
            Million, Advance Funded
        More than 40 years after the inception of public television, local
    stations continue to serve as the treasured cultural institutions
    envisioned by their founders, reaching America's local communities with
    unsurpassed programming and services. Furthermore, the power of digital
    technology has enabled stations to greatly expand their delivery
    platforms to reach Americans where they are increasingly consuming
    media--online and on-demand--in addition to on-air.
        However, at the same time that stations are expanding their
    services and the impact they have in their communities, stations are
    also facing unprecedented revenue declines--presenting them with the
    greatest financial challenge in their 40-year history. Every revenue
    source upon which our operations depend is under siege. State funding
    support is in a wholesale free-fall. Financial contributions from
    foundations and underwriters, at the local and national levels, have
    declined. Individual contributions, the bed-rock of every public
    station's annual operating budget, are dropping, reflecting the effects
    of rising unemployment and declining personal discretionary income. As
    such, increased Federal support for public broadcasting is perhaps more
    important now than ever before.
        Funds appropriated to CPB reach local stations in the form of
    Community Service Grants (CSGs). CSGs, while accounting for
    approximately 15 percent of the average station's overall budget, serve
    as the backbone of support for stations. Stations are also able to
    leverage those CSGs to raise additional funds from State legislatures,
    private foundations and their viewers.
        Funding through CPB is absolutely essential to public television
    stations. A 2007 GAO report concluded that Federal funding, such as
    CSGs, is an irreplaceable source of revenue, and that ``substantial
    growth of non-Federal funding appears unlikely.'' It also found that
    ``cuts in Federal funding could lead to a reduction in staff, local
    programming or services.''
        Federal support for CPB and local public television stations has
    resulted in a nationwide system of locally owned and controlled,
    trusted, community-driven and community responsive media entities. For
    the seventh consecutive year, a 2010 Roper poll rated public television
    the most trusted institution among nationally known organizations. And
    in a recent report, the American Academy of Pediatrics recommended that
    Congress increase funding for public television, characterizing it as
    ``the sole source for high quality, educational, noncommercial
    programming for children.''
        In addition, the advent of digital technology has created enormous
    potential for stations, allowing them to bring content to Americans in
    new, innovative ways while retaining our public service mission. Public
    television stations are now utilizing a wide array of digital tools to
    expand their current roles as educators, local conveners and vital
    sources of trusted information at a time when their communities need
    them most.
        For example, in an effort to address the decline of local
    journalism, CPB has just announced a significant investment in
    partnership with 28 local public television and radio stations to form
    seven regional journalism centers. The Centers will form teams of
    multimedia journalists, who will focus on issues of particular
    relevance to each region; their in-depth reports will be presented
    regionally and nationally via digital platforms, community engagement
    programs and radio and television broadcasts. For example, in the
    Plains, the project will focus on agribusiness including farming
    practices, food and fuel production. In the Upper-Midwest, the
    collaboration will focus on the changing economy of the region. In the
    Southwest, a bilingual reporting team will focus on cultural shifts
    that are transforming the southwest, including Latino, Native American,
    and border issues.
        In order for our stations to continue playing this vital role in
    their communities, APTS and PBS respectfully request $604 million for
    CPB, advance funded for fiscal year 2013. Advance funding is essential
    to the mission of public broadcasting. The longstanding practice
    ensures that stations are able to insulate programming decisions from
    political influence, leverage the promise of Federal dollars to raise
    State, local and private funds, and have the critical lead-in time
    needed to plan and produce programs.
    Digital Funding--Fiscal Year 2010 Request: $59.5 million
        Public television stations have been at the forefront of the
    digital transition, embracing the technology early and recognizing its
    benefits to their viewers. Fortunately, Congress wisely recognized that
    the Federal mandated transition to digital broadcast would place a
    hardship on public television's limited resources. Since 2001, Congress
    has provided public television stations with funds to ensure that they
    have the ability to continue to meet their public service mission and
    deliver the highest-quality educational, cultural and public affairs
    programming post-transition.
        Although the Federal mandated portion of the transition is
    complete, what remains to be finished is the ability of stations to
    fully replicate in digital their analog services. As stations have
    completed the transition of their main transmitters, they will continue
    to convert their master controls, digital storage equipment and other
    necessary studio equipment--necessary to produce and distribute local
    educational programming. This program is also critical to providing
    funds that can be invested in interactive public media that maximizes
    investments in digital infrastructure--including such content
    investments as the American Archive.
        Unlike most commercial broadcasters, public television has used
    this new public digital spectrum to maximize programming choices by
    offering an array of new channel options, including the national
    offerings of V-me (the first 24-hour, Spanish-language, educational
    channel), World, and Create.
        More importantly, stations have also used these multicast
    capabilities to expand their local offerings with digital channels
    dedicated to community or State-focused programming. Some stations have
    even utilized this technology to provide gavel-to-gavel coverage of
    their state legislatures. In addition, digital broadcasting has enabled
    stations to double the amount of noncommercial, children's educational
    programming offered to the American public.
        APTS and PBS respectfully request $59.5 million in CPB Digital
    funding for fiscal year 2011 to enable stations to fully leverage this
    groundbreaking technology.
    Ready To Learn and Ready to Teach (U.S. Department of Education)
        The President's budget proposed for the consolidation of both the
    Ready To Learn and Ready To Teach programs into larger grant programs.
    APTS and PBS are concerned that the consolidation of these programs
    could lead to, at worst, the elimination of these critical programs
    that Congress has seen fit to invest more than $216 million since
    fiscal year 2005. At best, under the proposed budget, these programs
    would cease to exist in their current structure, removing the
    mechanisms that have provided for the tremendous efficient and
    effective nature in which these programs successfully operate.
        Consolidation or elimination of these programs would severely
    affect the ability of local stations to respond to their communities'
    educational needs, removing the needed resources provided by these
    programs for children, parents and teachers. For example, our stations
    that participate in Ready To Learn or Ready To Teach activities in
    places such as Iowa (Iowa Public Television), Wisconsin (Wisconsin
    ECB), Washington (KCTS 9), Louisiana (Louisiana Public Broadcasting),
    Illinois (WSIU, WEIU), Arkansas (AETN), Pennsylvania (WPSU, WQLN, WITF,
    WVIA), Mississippi (Mississippi Public Broadcasting), New Hampshire
    (New Hampshire Public Television), Texas (KLRN, KLRU, KAVC, KAMU, KEDT,
    KMBH, KUHT, KNCT, KTXT, KOCV, KWBU), Alabama (Alabama Public
    Television) and Tennessee (WLJT, WNPT) would be severely impacted by
    the proposed consolidation.
        We urge that the subcommittee maintain the Ready To Learn and Ready
    To Teach programs as stable line-items in the fiscal year 2011 budget
    and resist the calls for consolidation. Additionally, we encourage the
    subcommittee to express their support for Ready To Learn and Ready To
    Teach as stable, Federal funded programs as Congress considers the
    reauthorization of the Elementary and Secondary Education Act which
    contains the authorizing language for both of these programs.
    Ready To Learn--Fiscal Year 2011 Request: $32 million
        With a specific target of at-risk children, Ready To Learn is
    improving the reading skills of all of America's children through fully
    researched, engaging educational television and on-line content, with a
    particular focus on more than 150,000 low-income households in 23
    States and the District of Columbia. Ready To Learn content, based on
    the findings of the National Reading Panel of 2000, is on-air-reaching
    99 percent of the country's television households through Public
    Television stations--as well as on-line, and on the ground in
    classrooms and communities.
        In addition to successful on the ground partnerships with local
    stations, national nonprofit organizations and State education leaders,
    including the Council of Chief State School Officers, Ready To Learn's
    signature component is its research-based and teacher-tested television
    programs that teach key reading skills, including: ``SUPER WHY!'',
    ``WordWorld'', ``Martha Speaks'', ``Sesame Street'', ``Between The
    Lions'', and ``The Electric Company'' produced by the best educational
    children's content producers.
        Recent evaluations of one such program, ``SUPER WHY!'', tell a
    story of enormous success.
        The evaluation found that preschool children who watched the
    program performed significantly better on most of the standardized
    measures of early reading achievement when compared with those
    preschool children who watched an alternate program. In fact, pre-test
    to post-test gains averaged 28.7 percent for ``SUPER WHY!'' viewers
    compared with an average gain of 13.2 percent for alternate program
    viewers. Specifically, preschool children demonstrated significant
    growth in targeted early literacy skills featured in ``SUPER WHY!'',
    including alphabet knowledge, phonological and phonemic awareness,
    symbolic and linguistic awareness, and comprehension.
        In addition, ``SUPER WHY!'s'' 2008 5-day Summer Reading Camps--33
    camps in 19 communities with 454 low-income Pre-K children--produced
    measurable results in raising children's reading skills through their
    interaction with strategically executed instructional materials
    designed to boost letter knowledge, decoding, encoding, and reading
    ability. During these camps, preschoolers showed an 84 percent gain in
    phonics skills and a 139 percent gain in word recognition skills.
        A separate study conducted by the University of Michigan, found
    that low income children who were exposed to Ready to Learn content
    used in formal curriculum preformed at nearly the same level as their
    higher income peers--effectively erasing the achievement gap.
        With additional funding, Ready To Learn can continue to meet the
    needs of those most lacking reading skills by extending the program's
    community engagement and partnership-driven work to additional high-
    need communities nationwide and by increasing capacity and reach
    through the innovative use of digital media.
        APTS and PBS respectfully request $32 million for Ready To Learn in
    fiscal year 2011.
    Ready To Teach--Fiscal Year 2011 Request: $17 million
        Ready To Teach was first introduced in Congress in 1994 as a
    demonstration project to show how distance learning technology coupled
    with public broadcasting's rich educational content could help teachers
    enhance their proficiency in specific curriculum areas.
        Later authorized under the No Child Left Behind Act, Ready To Teach
    currently funds the development of digital educational services aimed
    at enhancing teacher performance. Through four Ready To Teach
    services--PBS TeacherLine, e-Learning for Educators, VITAL and HELP--
    PBS, Alabama Public Television, Thirteen/WNET and Rocky Mountain PBS
    (RMPBS), have provided online professional development targeted toward
    Pre-K-12 educators, video clips aligned to math and reading State
    standards, and an English-Language Learner program for math
    instruction.
        Together, Ready To Teach programs have served nearly 500,000
    educators since 2001, and represent an enormously successful
    utilization of innovative, digital technology for the benefit of
    teachers and their students in the 21st century classroom.
        APTS and PBS respectfully request $17 million in fiscal year 2011
    in order to build the library of professional development courses,
    resources and support materials for teachers through the public
    broadcasting infrastructure, and increase the number of local stations
    able to participate in Ready To Teach, thereby increasing the efforts
    to prepare highly qualified teachers.
                                     ______

         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 Appropriations Subcommittee regarding funding for nursing- and
    rehabilitation-related programs in fiscal year 2011. ARN represents
    5,700 Registered Nurses (RNs) with 10,000 nurses certified in the
    specialty 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 illnesses and physical disabilities 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 condition, achieve their
    greatest potential, and work toward productive, independent lives. They
    take a holistic approach to meeting patients' nursing and 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 and care, including 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 maximum
    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 practices, 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 focused on nursing and
    medical rehabilitation, e.g., 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 (RNs) for
    individuals affected by chronic illness and/or physical disability.
        According to the Department of Health and Human Services, an
    estimated 36,750 nurses need to be recruited, educated, and retained
    through the Federal Nursing Workforce Development program at HRSA 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 July 2008, the American Health Care
    Association reported that more than 19,400 RN vacancies exist in long-
    term care settings. These vacancies, coupled with an additional 116,000
    open positions in hospitals reported by the American Hospital
    Association in July 2007, bring the total RN vacancies in the United
    States to more than 135,000. The demand for nurses will continue to
    grow as the baby-boomer population ages, nurses retire, and the need
    for healthcare intensifies. According to the U.S. Bureau of Labor
    Statistics (BLS), nursing is the Nation's top profession in terms of
    projected job growth, with more than 587,000 new nursing positions
    being created through 2016. Furthermore, BLS analysts project that more
    than 1 million new and replacement nurses will be needed by 2016.
        ARN strongly supports the national nursing community's request of
    $267.3 million in fiscal year 2011 funding for Federal Nursing
    Workforce Development programs at HRSA.
    National Institute on Disability and Rehabilitation Research (NIDRR)
        The National Institute on Disability and Rehabilitation Research
    (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 2011 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 healthcare 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 $160 million in fiscal year 2011 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 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 needed 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 2011
    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; $8 million for the HRSA Federal TBI
    State Grant Program; and $4 million for the HRSA Federal TBI Protection
    and Advocacy Systems Grant Program.
    Conclusion
        ARN appreciates the opportunity to share our priorities for fiscal
    year 2011 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 2011 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 &
                                 Ophthalmology

        The Association for Research in Vision & Ophthalmology (ARVO) has
    two major requests:
      --For Congress to fund the National Institutes of Health (NIH) in
            fiscal year 2011 at $35 billion; and
      --For Congress to make vision health a priority in the total funding
            of NIH by increasing National Eye Institute (NEI) funding more
            than the President's proposed 2.5 percent increase for NEI.
        The requested increase in the total NIH budget is a $3 billion
    increase more than President Obama's proposed funding level of $32
    billion. We are also concerned that NEI funding has been less than the
    increase for NIH funding for all funding cycles since 2001. NEI has
    lost 20.1 percent loss in purchasing power \1\ over the last 10 years,
    while NIH has lost 17.2 percent loss in purchasing power \1\ over the
    last 10 years.
    ---------------------------------------------------------------------------
        \1\ Calculations were based solely upon annual biomedical research
    and development price index and annual appropriated amounts.
    ---------------------------------------------------------------------------
        ARVO commends Congress for actions taken in fiscal year 2009 and
    fiscal year 2010 to fund NIH. This includes the $10.4 billion for NIH
    funding in the American Recovery and Reinvestment Act (ARRA). We also
    applaud the fact that the 2011 NIH budget draft, requesting a 3.2
    percent increase for NIH, keeps pace with inflation for the first time
    in 10 years. However, ARVO still has concerns about long-term,
    sustained and predictable funding for vision research at the NEI, which
    has lost approximately 3 percent more purchasing power \1\ than NIH in
    the past decade, which is not in proportion to the fact that vision
    disorders are the fourth most prevalent disability in the United States
    and the most frequent cause of disability in
    children.\2\-\5\
    ---------------------------------------------------------------------------
        \2\ 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.
        \3\ http://www.ncbi.nlm.nih.gov/pubmed/15078664
        \4\ http://www.healthypeople.gov/data/2010prog/focus28/2004fa28.htm
        \5\ http://www.preventblindness.org/vpus/
    ---------------------------------------------------------------------------
        ARVO also commends Congress for passing S. Res. 209 and H. Res.
    366, which acknowledged NEI's 40th anniversary as a free-standing
    institute and designated 2010-2020 as the Decade of Vision, in which
    the majority of 78 million baby boomers will turn age 65 and face great
    risk of developing aging eye diseases. In a 2007 report, age-related
    eye diseases were estimated to cost $51.4 million.\6\ Costs to
    healthcare also add up when more individuals with vision impairment
    live in nursing homes than would be the case if they had normal
    vision.\7\ NEI-funded research results in treatments and therapies that
    save vision, restore sight, reduce healthcare costs, maintain
    productivity, ensure financial independence, and enhance quality of
    life.
    ---------------------------------------------------------------------------
        \6\ http://www.preventblindness.org/research/
    Impact_of_Vision_Problems.pdf
        \7\ Archives of Ophthalmology. Vol. 124, No. 12:1754.
    ---------------------------------------------------------------------------
        ARVO requests $35 billion in NIH funding for fiscal year 2011,
    especially to ensure that NEI can build upon the impressive record of
    basic and clinical collaborative research that meets NIH's top five
    priorities and has been funded through fiscal year 2009-2010 ARRA and
    regular appropriations.
        NEI research addresses the top five NIH priorities, as identified
    by Dr. Collins: genomics, translational research, comparative
    effectiveness, global health, and empowering the biomedical
    enterprise.\8\ Such research also addresses the pre-emption,
    prediction, personalization (ex. gene therapy), and prevention of eye
    disease through basic, translational, epidemiological, and comparative
    effectiveness research. NEI continues to be a leader within NIH for
    elucidating the genetic basis of eye disease. NEI Director, Paul
    Sieving, MD, Ph.D. has reported that one-quarter of all genes
    identified to date through collaborative efforts with the National
    Human Genome Research Institute (NHGRI) are associated with eye
    disease/visual impairment.
    ---------------------------------------------------------------------------
        \8\ Science. Vol. 327:36.
    ---------------------------------------------------------------------------
        NEI received $175 million of the $10.4 billion in NIH ARRA funding.
    As a result, NEI's total funding levels in the fiscal year 2009-2010
    timeframe were $776 million and $794.5 million, respectively. In fiscal
    year 2009, NEI made 333 ARRA-related awards, the majority of which
    reflect investigator-initiated research that funds new science or
    accelerates ongoing research, including ten Challenge Grants. Several
    examples of research, and the reasons why it is important, include:
      --Biomarker for Neovascular Age-related Macular Degeneration (AMD).--
            Researchers are utilizing a recently discovered biomarker to
            develop an early detection method to minimize vision loss. This
            marker identifies a risk factor (for abnormal growth of blood
            vessels into the retina), which causes 90 percent of the vision
            loss associated with AMD. Importance: 1.75 million people were
            living with AMD in 2000, and the number is estimated to reach 3
            million by 2020.\9\ Without accounting for healthcare
            inflation, the most recent estimated of cost for AMD \10\
            treatment times 3 million is ($2.5-4.8 billion) over 5 years.
    ---------------------------------------------------------------------------
        \9\ Archives of Ophthalmology. Vol. 122, No. 4:564.
        \10\ Ophthalmology. Vol. 115, No. 1:18.
    ---------------------------------------------------------------------------
      --Cellular Approach to Treating Diabetic Retinopathy (DR).--
            Researchers are developing a clinical treatment for diabetic
            retinopathy by using specially treated stem cells from the
            patient's own blood to repair damaged vessels in the eye.
            Importance: DR is increasing in younger Americans and the aging
            population. In a 2004 paper, the reported prevalence was 4.1
            million Americans.\11\
    ---------------------------------------------------------------------------
        \11\ Archives of Ophthalmology. Vol. 122, No. 4:552.
    ---------------------------------------------------------------------------
      --Small Heat Shock Proteins as Therapeutic Agents in the Eye.--
            Researchers propose to develop new drugs to prevent or reverse
            blinding eye diseases, such as cataract (clouding of the lens),
            that are associated with the aggregation of proteins. Research
            will focus on the use of small ``heat shock'' proteins that
            facilitate the slow release and prolonged delivery of targeted
            macromolecules to degenerating cells of the eye. Importance:
            Delivering effective, long-lasting therapies through a
            minimally invasive route into the eye may help to reduce
            cataracts, the leading cause of low vision among all
            Americans.\12\
    ---------------------------------------------------------------------------
        \12\ http://www.nei.nih.gov/news/pressreleases/041204.asp
    ---------------------------------------------------------------------------
      --Identification of Genes and Proteins that Control Myopia
            Development.--Researchers propose to identify targets that will
            facilitate development of interventions to slow or prevent
            myopia (nearsightedness) development in children. Identifying
            an appropriate myopia prevention target can reduce the risk of
            blindness and reduce annual life-long eye care costs.
            Importance: More than 25 percent of the U.S. population has
            myopia, costing $14 billion annually, from adolescence to
            adulthood (data from NEI-supported study on myopia).\14\
    ---------------------------------------------------------------------------
        \14\ Archives of Ophthalmology. Vol. 101:405-407
    ---------------------------------------------------------------------------
      --Comparison of Interventions for Retinopathy of Prematurity (ROP).--
            In animal studies, researchers will simulate Retinopathy of
            Prematurity--a blinding eye disease that affects premature
            infants--and then study novel treatments that involve
            modulating the metabolism of the retina's rod photoreceptors.
            Importance: ROP affects 15,000 children a year, about 400-600
            of whom progress to blindness, at an estimated lifetime cost
            for support and unpaid taxes of $1 million
            each.\15\-\16\
    ---------------------------------------------------------------------------
        \15\ http://www.nei.nih.gov/news/pressreleases/041210b.asp
        \16\ http://www.actionfund.org/actionfund/
    Blindness_in_America.asp?SnID=2
    ---------------------------------------------------------------------------
      --The NEI Glaucoma Human genetics collaBORation, NEIGHBOR.--This
            research network, in which seven U.S. teams will lead genetic
            studies of the disease, may lead to more effective diagnosis
            and treatment. Researchers were primarily funded through ARRA
            supplements. Importance: Glaucoma, a complex neurodegenerative
            disease that is the second leading cause of preventable
            blindness in the United States, often has no symptoms until
            vision is lost.\17\
    ---------------------------------------------------------------------------
        \17\ http://www.glaucoma.org/learn/glaucoma_awaren.php
    ---------------------------------------------------------------------------
      --Comparative Effectiveness of Interventions for Primary Open Angle
            Glaucoma (POAG).--Researchers will evaluate existing data on
            the effectiveness of various treatment options for primary open
            angle glaucoma--many emerging from past NEI research.
            Importance: POAG is the most common form of the disease, which
            disproportionately affects African Americans and Latinos. It is
            estimated that 3.36 million individuals will have glaucoma by
            2020.\18\ This number times the average cost of treatment,\19\
            not accounting for inflation, is ($2.1-8.4 billion/year).
    ---------------------------------------------------------------------------
        \18\ Archives of Ophthalmology. Vol. 122, No. 4:532.
        \19\ Archives of Ophthalmology. Vol. 124, No. 1:12.
    ---------------------------------------------------------------------------
        In addition to ARRA funding, the ``regular'' appropriations
    increases in fiscal year 2009-2010 enabled the NEI to continue to fund
    key research networks, such as the following:
      --The African Descent and Glaucoma Evaluation Study (ADAGES), which
            is designed to identify factors accounting for differences in
            glaucoma onset and rate of progression between individuals of
            African and European descent. Importance: African Americans are
            more than three times as likely to develop visual impairment
            from glaucoma, compared to other ethnic groups.\20\
    ---------------------------------------------------------------------------
        \20\ http://www.nei.nih.gov/nehep/programs/glaucoma/goals.asp#data
    ---------------------------------------------------------------------------
      --The Diabetic Research Clinical Research Network's (DRCR) initiation
            of new trials comparing the safety and efficacy of drug
            therapies as an alternative to laser treatment for diabetic
            macular edema and proliferative diabetic retinopathy.
            Importance: In 2007, an estimated 23.6 million Americans were
            living with diabetes, and almost 1.6 million new cases were
            diagnosed per year. One out of 12 individuals with diabetes has
            diabetic retinopathy.\21\
    ---------------------------------------------------------------------------
        \21\ http://www.nei.nih.gov/strategicplanning/
    disparities_strategic_plan.asp#retinopathy
    ---------------------------------------------------------------------------
      --The Neuro-Ophthalmology Research Disease Investigator Consortium
            (NORDIC), which will lead multi-site observational and
            treatment trials, involving nearly 200 community and academic
            practitioners, to address the risks, diagnosis, and treatment
            of visual dysfunction due to increased intracranial pressure
            and thyroid eye disease.
      --Importance: A broad spectrum of neuro-ophthalmic disorders
            collectively affects millions of people. Many are associated
            with other neurological disease processes and have not been
            adequately investigated because they are rare. NORDIC will
            address unanswered questions about risks, diagnosis, and
            treatment that could not be studied without a clinical research
            organization.\22\
    ---------------------------------------------------------------------------
        \22\ http://www.nyee.edu/pdf/m_kupersmith.pdf
    ---------------------------------------------------------------------------
        The unprecedented level of fiscal year 2009-2010 vision research
    funding is moving our Nation that much closer to the prevention of
    blindness and restoration of vision. With an overall NIH funding level
    of $35 billion, which translates to an NEI funding level of $794.5
    million, the vision community can accelerate these efforts, thereby
    reducing healthcare costs, maintaining productivity, ensuring
    independence, and enhancing quality of life.
    Summary
        ARVO urges fiscal year 2011 NIH and NEI funding at $35 billion and
    $794.5 million, respectively.
                                     ______

        Prepared Statement of the American Society of Clinical Oncology

        The American Society of Clinical Oncology (ASCO), the world's
    leading professional organization representing more than 28,000
    physicians and other professionals who treat people with cancer,
    appreciates this opportunity to express our views on funding for the
    National Institutes of Health (NIH) for fiscal year 2011. ASCO's
    members set the standard for cancer patient care worldwide and lead the
    way in carrying out clinical research aimed at improving the screening,
    prevention, diagnosis, and treatment of cancer. ASCO's efforts are also
    directed toward advocating for policies that provide access to high-
    quality care for all patients with cancer and supporting the clinical
    and translational research in the area of oncology that is critical to
    improving the lives of our citizens.
        ASCO thanks the subcommittee for its continued investment in cancer
    research through the annual appropriations process, as well as through
    the American Recovery and Reinvestment Act (ARRA). The years of
    investment in cancer research are paying off in the most important
    ways--deaths rates are decreasing, survival rates are increasing, and
    treatments have fewer side-effects. Researchers are discovering that
    not only is cancer made up of hundreds of diseases, but these diseases
    have numerous subtypes that can be treated with targeted therapies.
    This translates to progress in treatments, as well as the need for
    exponentially more research.
        Without sustained and predictable increases in funding for NIH and
    the National Cancer Institute (NCI), the progress that has been made
    will be significantly delayed. On behalf of the cancer community, we
    wish to highlight that we are very grateful for the support of the
    administration and Congress, which resulted in NIH receiving an
    inflationary increase in fiscal year 2010. However, between 2004 and
    2008, NIH actually lost more than 13 percent of the purchasing power it
    had in 2003, the final year of the NIH budget doubling period.
        In addition to providing important economic stimulus to local
    communities throughout the United States provided through funding for
    research, the ARRA funding for research helped restore this significant
    decline in NIH purchasing power. With the ARRA funding, Congress
    temporarily reinstated the impact and spirit of doubling the NIH
    budget. Progress in fighting cancer would be faster, more efficient,
    and more sustainable if funding were equally steady and sustainable.

                  APPROPRIATIONS FOR FISCAL YEAR 2011 FOR NIH

        ASCO is joining with the biomedical research community in
    respectfully requesting the subcommittee appropriate $35 billion to NIH
    for fiscal year 2011. This request would maintain the total funding
    levels from fiscal year 2010 (including an annualized portion of the
    ARRA funds for research, which is 50 percent of the total ARRA funds
    for research), and allow us to sustain the pace of research made
    possible with ARRA. By adding an annualized portion of the research
    dollars provided by ARRA to the base budget of NIH, important
    advancements will continue to be made.
        Research is a long-term process and allowing the important work
    begun with ARRA funds will ensure faster progress in cancer research.
    Progress that has meaning and important positive impacts in patients'
    lives will continue to be made--it is a question of how quickly
    progress will be made going forward and whether researchers in the
    United States will continue to play a leadership role in pursuing these
    advancements.
        ASCO is also respectfully requesting that the subcommittee dedicate
    itself to a sustained, multi-year commitment to research funding.
    Meaningful progress cannot be made if NIH funding does not keep pace
    with the annual increase in the cost of conducting biomedical research.
    Unpredictable increases and decreases in NIH funding not only make it
    difficult for NIH to make commitments to multi-year projects, but also
    serve to discourage the best and brightest researchers to pursue
    careers in medical research. Sustained and predictable funding is key
    to a prosperous and vigorous biomedical research enterprise.

                                BENEFITS OF ARRA

        ARRA has given biomedical research a much needed boost in funding,
    but those funds are set to expire on September 30, 2010. ARRA has made
    it possible to enhance important research projects at NIH and the NCI,
    such as accelerating the identification of genomic alterations in tumor
    types in The Cancer Genome Atlas. This project is mapping cancer genes
    and will lead to increased understanding of how to target new
    treatments to halt the development and spread of cancer. Other uses of
    ARRA funds at NCI include the Accelerating Clinical Trials of Novel
    Oncologic PathWays (ACTNOW), the Cancer Human Biobank, and grants to
    Cancer Centers all across the country to promote personalized cancer
    care and drug development. These efforts are the beginning of a long-
    term process to translate discoveries into new treatments for cancer
    patients. Preservation of ARRA funds in the base NIH budget is
    necessary to translate these important discoveries into meaningful
    improvements in care for cancer patients.
        Funding cancer research also benefits local communities. According
    to a Families USA report, for every $1 in grants given by NIH, the
    economic benefit to the local community is, on average nationally,
    $2.21 in economic stimulus by way of new business activity, jobs and
    wages.

                   CLINICAL TRIALS AND TRANSLATIONAL RESEARCH

        In the area of oncology, clinical trials play a significant role in
    the day-to-day treatment options that should be available to patients,
    in large part because clinical trials often provide the best hope for
    successful treatment for cancer patients. NIH and NCI are leading the
    way by funding some very important data-driven translational research
    and clinical trials, bringing new, innovative therapies from research
    laboratories into clinics and hospitals to offer our patients targeted,
    personalized care. Clinical trials are absolutely critical to identify
    better, more cost effective care and longer lives for cancer patients.
    Translational research and clinical trials have changed the standard of
    care in many cancers.
        Clinical trials funded by NIH and NCI examine important questions
    that are not being investigated elsewhere, generate practice-changing
    science, and often recruit difficult to reach subpopulations.
    Unfortunately, these trials are at risk, due to concerns about
    inadequate funding, the pace of the trials and accrual rates. Clinical
    trials are increasingly being conducted overseas, due to the costs and
    regulatory complexities of conducting trials in the United States. This
    denies your constituents the opportunity to participate, either as a
    physician conducting research or as a patient enrolling, in a clinical
    trial. Congress must demonstrate a continued commitment to ensure
    biomedical research is federally funded. NIH research advances have
    transformed the way cancer is prevented, detected and treated, and
    cancer has become a much more survivable disease as a result.
        Federal funding has led to advances in screening that significantly
    contributed to the decline in cancer death rates. Federally funded
    clinical trials have also contributed directly to most patients having
    meaningful access to recommended chemotherapy regimens within their
    communities, often with far fewer side effects than in the past. Today,
    as a direct result of the investment in biomedical research (i.e.,
    clinical trials and translational research), we are implementing
    changes that are improving cancer care for our patients.
        Because of these advances and the incredible scientific
    opportunities facing us, ASCO urges the NIH and NCI to focus more of
    its resources in the area of clinical trials and translational
    research. Specifically, ASCO would also like to see an increase in the
    NCI per-case reimbursement for physicians who enroll patients on
    federally funded clinical trials. Studies conducted by ASCO and C-
    Change indicate that the current payment rate accounts for only half of
    the actual extra costs imposed on healthcare providers to enroll and
    participate within NCI-funded clinical trials. An ASCO survey of
    clinical trial sites in August 2009 revealed that a significant portion
    of sites are considering limits to their participation in federally
    funded research--in large part due to the inadequate funding provided.
    The funding NCI provides to sites that participate in their trials
    should be increased to account for actual research costs and keep pace
    with the growing costs of collecting and maintaining data and hiring
    skilled staff to oversee the research.
        ASCO again thanks the subcommittee for its continued dedication to
    Americans facing cancer through support of the important work
    accomplished under the guidance of NIH and NCI. We look forward to
    working with all members of the subcommittee to advance cancer
    research.
                                     ______

          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 2011 appropriation for the
    National Institutes of Health (NIH). The ASM is the largest single life
    science organization in the world with more than 40,000 members.
        The ASM is grateful for the support of Congress for the NIH, which
    is the single largest source of funding for biomedical research, with
    an annual budget of more than $31 billion. NIH supports extraordinary
    biomedical research successes, which are also critical to national
    security and a catalyst for the Nation's industrial, business, and
    education enterprises. To ensure continued biomedical research progress
    and to keep pace with the cost of conducting research, we recommend
    that Congress provide at least an 8 percent increase for NIH, and a
    higher level of funding, if possible.
    NIH Funding: The Need for Increased Funding for Biomedical Research
        In 2009, healthcare costs in the United States reached $2.5
    trillion, nearly 17 percent of the gross national product and more than
    any other nation, yet key health outcomes need improvement. Biomedical
    research offers innovative individual and population based medical
    interventions that will improve health and productivity. In fiscal year
    2011 the NIH will support emerging technology dependent areas like
    computational biology and DNA sequencing, as well as basic research and
    trans-NIH, multidisciplinary programs, including: (1) genomics and
    other high-throughput technologies; (2) translational medicine to
    expedite the path from basic research to clinical treatments and
    preventives; (3) greater focus on global health; (4) use of science in
    support of healthcare reform; and (5) revitalization of medical
    research, including training new scientists.
        In fiscal year 2011, NIH will support research by its own 6,000
    scientists and by nearly 325,000 other researchers at more than 3,100
    institutions, including medical schools, universities, and hospitals.
    About 83 percent of the fiscal year 2011 appropriation will fund
    extramural research, stimulating medical innovations, local economies,
    and the technical workforce needed to sustain the Nation's high-tech
    competitiveness. The Department of Health and Human Services funds 85
    percent of the country's life sciences research, primarily through the
    37,000 research project grants NIH will award in fiscal year 2011.
        Each dollar of NIH funding results in another $2 in business
    activity and other financial benefits. Last year, analysts found that
    20 percent of every NIH stimulus dollar spent under the 2009 American
    Recovery and Reinvestment Act (ARRA) purchased commercial products like
    software, instruments, and reagents, boosting technology-based
    industries and services. ARRA has enabled NIH to invest $10.4 billion
    over 2 years in NIH programs, distributed to researchers across the
    Nation through roughly 14,000 grants to date. ARRA stimulus funds to
    NIH ultimately will create or retain 50,000 jobs. ARRA funding clearly
    has stimulated NIH research, which until recently suffered years of
    stagnant or declining resources.
        With stimulus funds, NIH was able to support about 20 percent of
    grant applicants; but in fiscal year 2011, that figure likely will drop
    by half, to an historically low funding rate that will impinge medical
    innovation in the United States. NIH received more than 20,000
    proposals last year for new Challenge grants, which specifically
    support high-risk, high-return projects, but only 229 could be funded.
    Increased funding for NIH in fiscal year 2011 is essential to ensure
    that scientists can pursue research opportunities that will lessen the
    human burdens of disease and disability.
    NIH Funding: Foundation for Advances in Medicine
        Last September, NIH and the U.S. Army concluded their joint
    clinical trial in Thailand of a new AIDS vaccine, the first vaccine
    candidate to elicit a protective effect in humans against HIV
    infection. In 2009, NIH achieved advances in the global offensive
    against H1N1 influenza, most notably rapid development and
    implementation of clinical trials for various H1N1 vaccines. The three
    winners of the 2009 Nobel Prize in physiology or medicine had received
    more than $31 million in NIH research grants, while the three Nobel
    winners in chemistry received more than $17 million. Their respective
    studies on cellular aging and on the structure and function of
    ribosomes have transformed medical science and will continue to do so
    into the future.
        Worldwide, communicable diseases are responsible for 51 percent of
    the calculated ``years of life lost'' each year, according to the World
    Health Organization (WHO). Even in wealthy nations like the United
    States, preventable infectious diseases persist as leading causes of
    morbidity and mortality. The National Institute of Allergy and
    Infectious Diseases (NIAID) sponsors a range of research activity from
    diseases like malaria and HIV/AIDS, to immune system disorders,
    biodefense, and the antibiotic resistance among pathogenic microbes to
    drug treatments. NIAID focuses on nearly 300 pathogens that include
    bacteria, viruses, parasites, fungi and prions. New therapies,
    vaccines, diagnostics, and other products nurtured by NIAID have
    benefited every American and contributed in some way to global health.
        Influenza.--Approximately 86 million Americans have received 97
    million doses of 2009 H1N1 influenza vaccine largely developed and
    tested with the support of NIAID. Although the H1N1 pandemic has
    fortunately proved to be more moderate than originally feared, it still
    has produced an estimated 59 million U.S. cases since April 2009;
    265,000 hospitalizations; and 12,000 deaths. Stopping H1N1 requires
    thorough understanding of the viral pathogen's unique features. Ninety
    percent of seasonal flu deaths occur in those older 65, whereas 87
    percent of reported H1N1 deaths were patients under 65. In the past
    year, NIAID funded numerous H1N1 studies, including microscopic exams
    of respiratory tissue from fatal cases; lab experiments suggesting that
    H1N1 may outcompete seasonal flu virus strains and may be more
    communicable; a series of vaccine trials in different human
    subpopulations; and alternative vaccine production strategies,
    including tissue culture based vaccines and an early clinical trial of
    a candidate DNA vaccine, an experimental class of vaccine where a
    pathogen's genetic material is injected directly into the body.
        HIV/AIDS.--In fiscal year 2011, The NIH will spend nearly $3.2
    billion for research on HIV/AIDS, which remains one of the most
    intractable health challenges faced by the world. An estimated 33
    million people are living with HIV worldwide, and another 2 million
    have died. Each year, there are 56,300 new HIV infections in the United
    States; of the estimated 1.1 million Americans living with HIV, 21
    percent are unaware of their infection. The NIAID's Vaccine Research
    Center investigates multiple approaches to new vaccine development,
    like how neutralizing antibodies develop during natural HIV infection,
    which could point to an effective vaccine. NIAID also supports other
    prevention strategies, such as using antiretroviral drugs to stop
    mother to child HIV transmission (an estimated 430,000 children became
    infected in 2008, mostly through birth or breastfeeding from an HIV
    infected mother). In 2009, NIAID outlined its ``test and treat''
    prevention agenda, based on a WHO mathematical model predicting that
    universal, voluntary, annual HIV testing and immediate treatment for
    those who test positive could radically reduce HIV incidence within a
    decade, and potentially end the pandemic within 50 years.
        Global Health Infectious.--Diseases can quickly spread through the
    world's populations and across national borders. Global health research
    at NIAID informs science based public health policies worldwide, and
    the institute participates in several global partnerships with entities
    like WHO and UNICEF. It also has interagency agreements with USAID,
    CDC, NASA, and the State Department to combat diseases that migrate
    from country to country. With its scientific expertise in major global
    diseases, NIAID will be a vital contributor to the Administration's new
    Global Health Initiative (GHI) designed to reform and coordinate U.S.
    support for international health. NIAID has established programs tied
    to four of the six GHI focus areas, that is, HIV/AIDS, tuberculosis,
    malaria, and neglected tropical diseases (also, health systems and
    health workforce; maternal, newborn, and child health).
        Malaria.--This disease threatens an estimated 3.3 billion people,
    nearly half of the world's population. Each year, this age-old disease
    causes about 250 million clinical cases and nearly 1 million deaths,
    most of those deaths in and children under 5 years and pregnant women.
    At least four species of the causative Plasmodium protozoa are
    transmitted through bites from dozens of Anopheles mosquito species,
    all of which can develop resistance to known pesticides and
    antimalarial drugs and a fifth human malaria parasite was recently
    discovered in Asia. The complex parasite vector human host cycle ranks
    malaria among medicine's grand challenges. NIAID funds basic and
    applied research to develop tools and strategies for the treatment,
    prevention, and control of this disease.
        One-third of the world's population is infected with the pathogen
    Mycobacterium tuberculosis. There are 9.4 million new tuberculosis
    cases annually and 1.8 million deaths, making TB the leading cause of
    global mortality after HIV/AIDS. Public health efforts against TB are
    often outmoded, the mostly commonly used diagnostics were developed a
    century ago, there have been no new drugs introduced for decades, and
    the last new vaccine was produced 40 years ago. Therapy is difficult at
    best, and the emergence of drug-resistant strains has greatly
    complicated treatment. TB cases classified as ``extensively drug
    resistant'' (XDR) now occur in nearly 60 nations, with mortality rates
    exceeding 95 percent in some areas. NIAID funding supports research to
    discover updated diagnostics, therapeutics, and vaccines.
        The so called ``neglected tropical diseases'' (NTDs) like
    leishmaniasis, sleeping sickness, and Chagas disease cumulatively
    infect more than 1 billion people and kill 534,000 per year. WHO
    categorizes 14 diseases as NTDs important to global health, serious
    illnesses that most often affect impoverished countries. Many are often
    fatal, usually ignored by control and treatment programs, and
    associated with poor surveillance tools and systems. NIAID conducts
    research on selected NTDs.
    NIH Funding: Defense Against Emerging Infectious Diseases
        The proposed fiscal year 2011 budget increases funding for NIAID's
    activities emerging infectious diseases. These diseases might migrate
    or evolve naturally, perhaps developing resistance to standard drug
    treatments, or their pathogens might be deliberately dispersed as
    agents of bioterrorism. NIAID funding has created countermeasures
    against anthrax, botulinum toxin, and smallpox.
        In recent years, alarmed public health officials have devoted
    increasing resources toward mitigating the social and economic impacts
    of antimicrobial resistance. NIAID supports multiple projects devoted
    to the biological aspects of this problematic phenomenon. Drug
    resistant pathogens of greatest concern include methicillin resistant
    Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE),
    and the microbial causes of malaria, HIV/AIDS, influenza, tuberculosis,
    streptococcal pneumonia, and various foodborne illnesses. Many
    resistant infections develop in healthcare settings. Each year, about 2
    million people develop infections in U.S. hospitals, with 90,000
    deaths. About 70 percent of those infections are linked to pathogens
    resistant to at least one drug. Data now indicate that the problem
    outside healthcare settings is greater than originally believed. In
    fiscal year 2011, NIAID will fund a new initiative, Development of
    Therapeutic Products for Biodefense, with particular emphasis on broad
    spectrum products or those addressing the growing dilemma of
    antimicrobial resistance.
    NIH Funding: Moving Forward in Biomedical Research
        Discoveries through NIAID and NIGMS programs have fostered
    breakthrough tools and methods vital to sectors of the US medical
    enterprise, like biotechnology. Research strategies at NIH must take
    advantage of cutting edge technologies and modern scientific
    disciplines like genomics and bioinformatics. NIAID research
    partnerships will develop next-generation biodefense diagnostics, like
    those using nanotechnology-based microfluidic platforms, in vivo
    imaging methods, or other emerging technologies.
        By supporting high-risk, high-return projects, NIGMS lays the
    foundation for future advances in disease diagnosis, treatment, and
    prevention. It promotes large-scale initiatives to solve complex
    problems through collaborative research. An example is the NIGMS
    pharmacogenetics research program, which integrates laboratory science
    and databases linking genes, medicines, and diseases. In December,
    NIGMS announced five new projects in its pharmacogenomics collaboration
    with Japan's Center of Genomic Medicine; one will examine why
    antiretrovirals used to treat HIV are not effective in some people.
        NIH funding also invests in the future by building the workforce
    needed to sustain innovation. Each year, NIH also provides grants for
    STEM education across the United States, and supports pre- and
    postdoctoral scientists at the NIH campus or with fellowships
    elsewhere. NIGMS alone supports approximately 50 percent of Ph.D.
    training positions at NIH.
        NIH plays a key role in accelerating transformation of basic
    science into clinical tools that save lives. The ASM recommends that
    Congress approve at least an 8 percent increase for the National
    Institutes of Health.
                                     ______

          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 2011 appropriation for the
    Centers for Disease Control and Prevention (CDC). The ASM is the
    largest single life science organization in the world with more than
    40,000 members.
        The ASM is very concerned that the proposed CDC budget of $6.6
    billion for fiscal year 2011 is 2 percent below the fiscal year 2010
    appropriation. The administration's proposed budget is inconsistent
    with the need to adequately fund the agency acknowledged to be the
    principal Federal driver in meeting our Nation's goals for enhanced
    prevention and wellness. Focusing only on the infectious disease
    component of the CDC budget, the ASM notes that the administration has
    proposed a $19.6 million increase in this area. However, such a modest
    increase does not adequately address the growing complexity and
    challenges of emerging infectious diseases. These challenges have been
    abundantly evident over the past year with the H1N1 influenza pandemic.
    Furthermore, the proposed budget substantially decreases two priority
    program areas: the CDC's vector-borne diseases program (by $26.7
    million, which will essentially eliminate the program), and the CDC's
    antimicrobial resistance program (by $6.8 million). In the fiscal year
    2011 budget, both programs are to be supported out of emerging
    infectious disease funds. Therefore, the proposed increase of $19.6
    million for emerging infectious diseases is insufficient to offset the
    $34 million in proposed reductions for vector-borne diseases and
    antimicrobial resistance, resulting in a net decrease of $15 million
    for emerging infectious diseases.
        Eliminating funding for the vector-borne diseases program will
    impair CDC's collaborations with State and local partners consisting of
    vector-borne disease surveillance, outbreak response, the development
    of new diagnostics, diagnostic training and proficiency testing, as
    well as applied research and prevention efforts to address arboviral
    diseases. In the proposed budget, it is unclear what, if any, support
    will be available in fiscal year 2011 for prevention and control of
    vector-borne pathogens. This funding reduction will essentially destroy
    the infrastructure developed in the past decade in response to the
    importation of West Nile virus in 1999 and its subsequent spread across
    the United States, and will leave the country vulnerable to similar
    importation of other vector-borne diseases. In view of the net
    reduction for infectious diseases of approximately $15 million, the ASM
    recommends that Congress increase the budget for emerging infectious
    diseases and for CDC by at least 8 to 10 percent, to restore and
    strengthen funding for infectious disease prevention and control and
    other priority public health programs.
        Vector-borne Diseases.--The administration's proposed elimination
    of funding (-$26.7 million) for vector-borne diseases, including West
    Nile Virus, in its fiscal year 2011 budget will have serious
    repercussions. Many emerging or re-emerging infectious diseases are
    tied to pathogens transmitted from animals to humans, often through
    insect vectors. CDC programs protect public health through ``one
    health'' strategies, based on the understanding that human health is
    intertwined with the health of animals and the environment. The vector-
    borne program not only supports the West Nile virus activities, but
    also supports work on agents like plague, tularemia, Lyme disease,
    dengue fever, and Japanese encephalitis. Lyme disease is by far the
    most common tickborne infection in the United States and exacts an
    enormous toll in healthcare costs and lost productivity. The U.S.
    mainland is constantly threatened by the potential for establishment of
    dengue virus, as occurred last year in the Florida Keys. Emerging
    public health risks like chikungunya virus in South Asia and the Indian
    Ocean are an ongoing concern similar to West Nile. To appropriately
    address vector-borne infections requires a vibrant infrastructure for
    detection, diagnosis, response and prevention at the national, State,
    and local level. The proposed budget cuts will substantially dismantle
    the system developed in response to West Nile virus, causing much of
    the $200 million investment over the last decade to disappear. ASM
    urges the Administration to restore the vector borne disease funding.
        Antimicrobial Resistant Infections.--The administration's proposed
    budget reduces the antimicrobial resistance program by $6.8 million.
    The ASM disagrees with the proposed fiscal year 2011 decreases for
    crucial CDC efforts at a time when drug-resistant pathogens continue to
    emerge in both the community and healthcare setting. The decrease will,
    among other negative outcomes, substantially cut funding to States for
    surveillance and control programs. As a partner in the Federal
    Interagency Action Plan to Combat Antimicrobial Resistance, CDC has
    been instrumental in tracking the grim increase in microbial pathogens
    resistant to antimicrobial drugs, like methicillin-resistant
    Staphylococcus aureus (MRSA). Invasive MRSA infections attack about
    94,000 Americans annually, contributing to 19,000 deaths. MRSA is an
    increasing problem in community settings where different control
    strategies are necessary than in the hospital environment. A similar
    trend is being seen with Clostridium difficile, an organism once
    largely confined to hospital and nursing home settings but now
    associated with increasing severity in the community. Microbial drug
    resistance is driven by various factors, from pathogens' natural
    evolution to the growing use of antimicrobials in human and animal
    healthcare. One estimate suggests that between 5 and 10 percent of all
    hospitalized U.S. patients acquire a drug-resistant infection, adding
    $5 billion in annual healthcare costs. CDC either leads or collaborates
    in multiple projects against antimicrobial resistance, like the World
    Health Organization (WHO) effort to reduce the global spread of
    cephalosporin-resistant gonorrhea. Reduced funding would seriously
    impact the ability to mount and sustain programs to confront the
    problem of antimicrobial resistant pathogens.
    CDC Funding: The Need for Increased Resources
        While life expectancy has steadily increased, influenza, pneumonia,
    and septicemia caused by microbial pathogens remain among the top 10
    causes of death. The sudden emergence of pandemic H1N1 in the spring of
    2009 in Mexico, California, and Texas highlights the profound impact
    infectious diseases can have on our well being and economy. In addition
    to such emergent threats, other infectious diseases are on the rise.
    Reported cases of sexually transmitted Chlamydia infections have more
    than tripled since 1990, making it the most commonly reported
    infectious disease in the United States. Each year, children are absent
    38 million school days due to influenza. About 43,000 Americans still
    develop acute hepatitis B annually, despite effective vaccines. The
    estimated annual cost to U.S. hospitals of treating healthcare
    associated infections ranges from $28.4 billion to $45 billion.
    Foodborne illnesses continue to produce tens of millions of infections
    annually. And each year, Americans visit physician offices, hospital
    outpatient units or emergency rooms for infectious and parasitic
    diseases an estimated 30 million times.
        The CDC Office of Infectious Diseases (OID) has three programs to
    prevent numerous microbial diseases: the National Center for
    Immunization and Respiratory Diseases, the National Center for Emerging
    and Zoonotic Infectious Diseases and the National Center for HIV/AIDS,
    Viral Hepatitis, STD and TB Prevention. The CDC's Center for Global
    Health and other agency offices add expertise to the fight against
    disease pathogens here and abroad. In the past year, CDC personnel have
    contributed to the fight against H1N1 influenza and identified or
    confirmed the causes of disease outbreaks nationwide. They monitor
    drug-resistant tuberculosis and other communicable diseases at U.S.
    ports of entry, and collaborate with local, State, Federal, and
    international partners to protect and promote good health in countries
    such as Haiti in response to the recent catastrophic earthquake.
    Monitoring Disease, Protecting Public Health
        HIV/AIDS.--CDC estimates that about 1.1 million persons in the
    United States are living with HIV or AIDS; an estimated 21 percent do
    not know that they are infected. With life saving antiretroviral
    treatments now available, earlier diagnosis is the goal of recent CDC
    guidances on opt-out testing in correctional institutions and other
    settings and for routine screening in all healthcare settings for those
    aged 13-64 years and pregnant women, and retesting at least annually
    for all at high risk. In November, CDC reported that HIV incidence
    among intravenous drug users had declined by nearly 80 percent since
    the late 1980s, a positive public health outcome, yet late diagnosis of
    new infections persists. The fiscal year 2011 budget increases funds
    for a National HIV/AIDS Strategy under development, to include renewed
    efforts toward HIV risk reduction.
        Hepatitis.--Two percent of the U.S. population or an estimated 5.3
    million are living with chronic hepatitis B (HBV) or hepatitis C (HCV),
    most unaware of their infection unless they later develop liver disease
    or cancer. Last year, a CDC study concluded that in the previous
    decade, failures by healthcare workers to follow basic infection
    control practices had placed more than 60,000 U.S. patients at risk for
    HBV or HCV infection. In January, the Institute of Medicine called for
    a new, improved national strategy to prevent and control these
    infections. Each year an estimated 25,000 persons become infected with
    hepatitis A (HAV), even though rates of acute symptomatic cases have
    declined by 92 percent since a vaccine first became available in 1995.
    CDC now recommends HAV vaccine for all children at age one, since
    children are a major source of infection for adults who can develop
    more serious symptoms. CDC reported last year that vaccination among
    U.S. children increased from about 26 percent in 2006 to more than 47
    percent in 2007, but this means that still over half of our children
    are needlessly at risk of a fully preventable disease like hepatitis A.
    They also serve as a source of infection to vulnerable adults.
        Tuberculosis.--In a new CDC report, preliminary statistics from the
    agency's National TB Surveillance System reveals that 2009 saw the
    largest single year decrease in U.S. cases since data collection began
    in 1953. The 11,540 cases reported last year were roughly 11 percent
    fewer than the previous year, with declines in both U.S.- and foreign-
    born persons, although the TB rate among foreign born was still nearly
    11 times higher. Possible explanations for the unprecedented drop,
    which CDC is investigating, include failure to recognize, diagnose, or
    report the disease due to weakening infrastructure or diversion of
    public health resources to the H1N1 response. This would represent a
    serious setback to TB disease control and elimination efforts in the
    United States. The emergence of tuberculosis bacteria resistant to
    available antimicrobial drugs has alarmed health organizations
    worldwide. CDC scientists identified genetic mutations associated with
    drug resistance in tuberculosis bacteria, which are now included in CDC
    laboratory testing available to State public health laboratories.
        Foodborne/Waterborne Illness.--A recent study estimates that the
    total economic impact of foodborne illness in the United States reaches
    $152 billion annually. Last April, CDC reported that progress in
    foodborne illness prevention had reached a plateau, with the incidence
    of the most common foodborne illnesses stagnating over the previous 3
    years after several years of decline in the late 1990s and early 2000s.
    Of particular concern is the incidence of Salmonella infections, which
    persists at 14-16 cases per 100,000 Americans and periodically causes
    disease outbreaks. CDC reports the following foodborne illnesses: (1)
    of the 1,270 outbreaks in 2006, 621 had a confirmed single cause, most
    often norovirus (54 percent), followed by Salmonella (18 percent); and
    (2) foods tied to the largest number of outbreak cases were poultry (21
    percent), leafy vegetables (17 percent) and fruits-nuts (16 percent).
    The ASM commends the appreciable increases in fiscal year 2011 funding
    for food safety activities that will boost CDC capabilities, such as
    expanded outbreak surveillance and standardized investigations at the
    State and local level. The proposed fiscal year 2011 budget
    specifically supports CDC water quality programs, including expansion
    of its Safe Water System and Water Safety Plan to additional countries
    to reduce waterborne diseases like cholera, giardiasis and
    cryptosporidioisis.
    Preventing Disease, Protecting Public Health
        Over the past year, considerable CDC resources focused on
    preventing H1N1 influenza. Americans have received 97 million doses of
    H1N1 vaccine via CDC distribution systems. Although the pandemic has
    been less severe than originally feared, it has still resulted in an
    estimated 55 million U.S. cases since April 2009, 246,000
    hospitalizations and 11,000 deaths, many in infants, children, and
    young adults. CDC testing determined that many Americans who died from
    H1N1 had co-infections with the common pneumonia bacterium,
    Streptococcus pneumoniae, which likely contributed to their death.
    Unfortunately, vaccine preventable pneumococcal infections still kill
    an estimated 40,000 Americans each year. CDC officials are currently
    assessing the lessons learned during the 2009-2010 influenza season.
        In February, CDC recommended universal use in children of an
    updated pneumococcal vaccine just approved by the Food and Drug
    Administration, which should greatly reduce S. pneumoniae infections
    and stop a leading cause of bacteremia, meningitis and pneumonia.
    Pneumonia kills nearly 2 million children each year, most in
    impoverished nations.
    Improving Preparedness and Response
        Being prepared for the unexpected is one of CDC's primary
    responsibilities in protecting our health and well-being. During an
    emergency, CDC can quickly convene expert teams and deploy both
    personnel and medical supplies anywhere in the world. CDC leads Federal
    efforts to detect and contain biothreats and to ensure availability of
    medical countermeasures. It operates the Strategic National Stockpile,
    a repository of countermeasures for rapid deployment, as well as its
    quarantine stations at the Nation's borders. It distributes grants to
    State and local health departments to build capacity against public
    health emergencies and acts of terrorism. The ASM supports the proposed
    additional fiscal year 2011 funds to improve CDC's overall preparedness
    and response efforts, including the Laboratory Response Network and
    Select Agent Program.
        In light of the significant role played by the CDC as the Nation's
    first line of defense against a host of infectious disease threats and
    its leadership in national efforts to promote wellness and prevention,
    these efforts should not be handicapped by a funding reduction as
    proposed in the 2011 budget. The ASM supports an 8 to 10 percent
    increase in infectious disease activities to assure critical programs
    are not reduced or eliminated and that opportunities to prevent and
    control infectious diseases are not curtailed. ASM appreciates the
    opportunity to comment on the fiscal year 2011 budget for the CDC.
                                     ______

       Prepared Statement of the American Society of Mechanical Engineers

        The NIH Task Force (``Task Force'') of the Inter Sector Committee
    on Federal Research and Development (ISCFRD) of ASME is pleased to
    provide comments on the bioengineering-related programs contained
    within the National Institutes of Health (NIH) fiscal year 2011 budget
    request. The Task Force is focused on the application of mechanical
    engineering knowledge, skills, and principles for the conception,
    design, development, analysis, and operation of biomechanical systems.
    The Importance of Bioengineering
        Bioengineering is an interdisciplinary field that applies physical,
    chemical, and mathematical sciences, and engineering principles to the
    study of biology, medicine, behavior, and health. It advances knowledge
    from the molecular to the organ levels, and develops new and novel
    biologics, materials processes, implants, devices, and informatics
    approaches for the prevention, diagnosis, and treatment of disease, for
    patient rehabilitation, and for improving health. Bioengineers have
    employed mechanical engineering principles in the development of many
    life-saving and life-improving technologies, such as the artificial
    heart, prosthetic joints, diagnostics, and numerous rehabilitation
    technologies.
    Background
        The NIH is the world's largest organization dedicated to improving
    health through medical science. During the last 50 years, NIH has
    played a leading role in the major breakthroughs that have increased
    average life expectancy by 15 to 20 years.
        The NIH is comprised of different Institutes and Centers that
    support a wide spectrum of research activities including basic
    research, disease and treatment-related studies, and epidemiological
    analyses. The mission of individual Institutes and Centers varies from
    either study of a particular organ (e.g., heart, kidney, eye), a given
    disease (e.g., cancer, infectious diseases, mental illness), a stage of
    life (e.g., childhood, old age), or finally it may encompass
    crosscutting needs (e.g., sequencing of the human genome and the
    National Institute of Biomedical Imaging and Bioengineering (NIBIB).
        The total fiscal year 2011 NIH budget request is $32.2 billion, or
    3.2 percent above the $31.2 billion fiscal year 2010 appropriated
    amount. The Task Force recognizes that this proposed increase is
    significant given the administration's commitment to reducing the
    Federal deficit. However, the Task Force notes that the
    administration's 3.2 percent increase to the overall NIH budget is less
    than the up to 3.8 percent projected increase in research costs due to
    inflation--as predicted by the Biomedical Research and Development
    Price Index (BRDPI)--and as a consequence actually results in an
    effective decrease in funding for the NIH compared to fiscal year 2010.
    The Task Force therefore recommends out-year budget increases well
    beyond BRDPI inflation rates to compensate for this flat level of
    funding.
        The Task Force further notes that NIH received $10.4 billion as
    part of the American Recovery and Reinvestment Act (ARRA) of 2009
    (Public Law 111-5), an important influx for several key divisions of
    NIH over the fiscal year 2009 and fiscal year 2010 funding cycles,
    particularly the NIBIB, which received $78 million--less than 1 percent
    of the $10.4 billion ARRA budget assigned to the NIH for the fiscal
    year 2009 and fiscal year 2010 funding cycles. NIBIB has already
    exhausted approximately 95 percent of this budget, leaving little ARRA
    funding to leverage through the fiscal year 2010 budget cycle and
    underscore the need for more robust investment in bioengineering at
    NIBIB. While this one-time influx of funding for health research and
    infrastructure was justified, the Task Force notes that the unstable
    nature of such funding inhibits the potential impact on the economy and
    should not be viewed as a viable substitute for steady and consistent
    support from Congress for these critical national research priorities.
        Overall research and development activities are expected to account
    for 97.4 percent of the total fiscal year 2011 NIH budget, or $31.4
    billion. With this, the administration estimates 9,052 research project
    grants (RPGs) will be supported, 199 less than fiscal year 2010,
    essentially flat year-on-year. Of the administration's priority
    programs this year, the Task Force commends the recommended $382
    million in support for the National Nanotechnology Initiative, a 6
    percent or $22 million increase over fiscal year 2010.
    NIBIB Research Funding
        The administration's fiscal year 2011 budget requests $325.93
    million for the NIBIB, an increase of $9.47 million or 3 percent from
    the fiscal year 2010 appropriated amount. This increase is less than
    the 3.8 percent projected increase in research costs due to inflation
    (predicted by the BRDPI index) and, as a consequence, actually results
    in an effective decrease in funding for NIBIB compared to fiscal year
    2010. The mission of the NIBIB is to seek to improve human health by
    leading the development and application of emerging and breakthrough
    technologies based on a merging of the biological, physical, and
    engineering sciences.
        The budget for NIBIB Research Grants would increase by $6.1 million
    to $268.8 million, a 2.4 percent increase from fiscal year 2010.
    Funding for intramural research would increase 3.6 percent to $11.5
    million from $11 million in fiscal year 2010. NIBIB's Research
    Management and Support request is $17.7 million, a 5.4 percent increase
    or $0.84 million over fiscal year 2010.
        NIBIB funds the Applied Science and Technology (AST) program, which
    supports the development and application of innovative technologies,
    methods, products, and devices for research and clinical application
    that transform the practice of medicine. The fiscal year 2011 request
    for AST is $176.8 million, a $5.2 million increase or 3 percent from
    fiscal year 2010.
        Additionally, NIBIB funds the Discover Science and Technology (DST)
    program, which is focused on the discovery of innovative biomedical
    engineering and imaging principles for the benefit of public health.
    The fiscal year 2011 request for DST is $95.1 million, a $2.2 million
    or 2.4 percent increase from fiscal year 2010.
        The Technological Competitiveness-Bridging the Sciences program,
    which funds interdisciplinary approaches to research, would receive
    $24.9 million in fiscal year 2011, a $0.9 million increase or 3.6
    percent over the fiscal year 2010 enacted level.
    Task Force Recommendations
        The Task Force is concerned that the United States faces rapidly
    growing challenges from our counterparts in the European Union and Asia
    with regards to bioengineering advancements. While total health-related
    U.S. research and development investments have expanded significantly
    over the last decade, investment in bioengineering at NIBIB have
    remained relatively flat over the last several years. In fact, the
    fiscal year 2011 budget actually represents a small reduction in
    funding when the fiscal year 2003 NIBIB appropriation of $280 million
    is adjusted for inflation ($329 million in 2010 dollars).
        The Task Force wishes to emphasize that, in many instances,
    bioengineering-based solutions to healthcare problems can result in
    improved health outcomes and reductions in healthcare costs--a
    fundamental tenet of the President's National Innovation Strategy. For
    example, coronary stent implantation procedures cost approximately
    $20,000, compared to bypass graft surgery at double the cost. Stenting
    involves materials science (metals and polymers), mechanical design,
    computational mechanical modeling, imaging technologies, etc. that
    bioengineers work to develop. Not only is the procedure less costly,
    but the patient can return to normal function within a few days rather
    than months to recover from bypass surgery, greatly reducing other
    costs to the economy. Therefore, we strongly urge Congress to consider
    increased funding for bioengineering within the NIBIB and across NIH,
    and work to strengthen these investments in the long run to reduce U.S.
    healthcare costs and support continued U.S. leadership in
    bioengineering.
        The NIBIB must obtain sustained funding increases, both to
    accelerate medical advancements as our Nation's population ages, and to
    mirror the growth taking place in the bioengineering field. The Task
    Force believes that the administration's budget request for fiscal year
    2010 is not aligned with the challenges posed by this objective; a 3
    percent budget increase will not keep up with current inflationary
    increases for biomedical research, eroding the United States' ability
    to lay the groundwork for the medical advancements of tomorrow.
        While the Task Force supports Federal proposals that seek to double
    Federal research and development in the physical sciences over the next
    decade, we believe that strong Federal support for bioengineering and
    the life sciences is especially essential to the health and
    competitiveness of the United States. The supplemental funding that NIH
    received as part of ARRA and the budget request by the administration
    does not completely erase the past several years of disappointing
    budgets. Congress and the administration should work to develop a
    specific plan, beyond President Obama's call for ``innovations in
    healthcare technology'' in his ``Strategy for American Innovation'', to
    focus on specific and attainable medical and biomedical research
    priorities which will reduce the costs of healthcare and improve
    healthcare outcomes. Further, Congress and the administration should
    include in this strategy new mechanisms for partnerships between NSF
    and the NIH to promote bioengineering research and education. The Task
    Force feels these initiatives are necessary to build capacity in the
    U.S. bioengineering workforce and improve the competitiveness of the
    U.S. bioengineering research community.
                                     ______

            Prepared Statement of the American Society for Nutrition

        The American Society for Nutrition (ASN) appreciates this
    opportunity to submit testimony regarding fiscal year 2011
    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 $37 billion
    for NIH, and we request $162 million for NCHS in fiscal year 2011.
        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--the NIH and the NCHS .
    NIH
        NIH is the Nation's premier sponsor of biomedical research and is
    the agency responsible for conducting and supporting 90 percent (more
    than $1.4 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
    2011 funding level of $37 billion for the agency.
        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. Thanks to Congress' inclusion of
    nearly $10 billion for NIH in H.R. 1, the American Recovery and
    Reinvestment Act, the scientific enterprise has been revitalized and
    additional biomedical research projects have been supported. ASN was
    pleased to see that more than 2 years. These projects also are, in
    addition to generating new findings to improve human health and
    nutrition, providing jobs and generating commercial activity throughout
    the broader community. 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 research engine needs predictable, sustained investment in
    science to maximize our return on investment. Recent experience has
    demonstrated how cyclical periods of rapid funding growth followed by
    periods of stagnation is disruptive to the discovery process, can lead
    to fewer students choosing careers in research, impedes long-range
    projects and ultimately slows 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 National Center for Health Statistics
        The National Center for Health Statistics (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.
    Not surprisingly, NHANES serves as a gold standard for nutrition and
    health data collection around the world.
        For several years, flat and decreased funding levels threatened the
    collection of this important information, most notably vital statistics
    from the NHANES. Beginning in fiscal year 2009, Congress made a renewed
    commitment to this agency by appropriating an additional $11 million to
    the agency--for nearly $125 million total--in fiscal year 2009 and a
    $14 million boost in fiscal year 2010. Actions in fiscal year 2009
    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. Last year's continued support enabled the
    agency to rebuild after years of underinvestment. ASN appreciates very
    much the leadership this subcommittee has shown in securing steady and
    sustained funding increases for NCHS over the past 3 fiscal years.
        To continue support for the agency and its important mission, ASN
    supports the President's fiscal year 2011 budget request of $162
    million for the agency.
        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.\1\
    ---------------------------------------------------------------------------
        \1\ Institute of Medicine. Progress in Preventing Childhood Obesity
    Washington, DC: National Academies Press, 2006.
    ---------------------------------------------------------------------------
        Now that healthcare reform has been signed into law, collecting
    health statistics is of even greater importance. Providing an
    additional $23 million in fiscal year 2011 continues the progress on a
    path that can mitigate previous years of flat-funding and ensure we
    have a 21st century health statistics system in the United States.
        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.
        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 discovery of new drugs and therapies.
    Although NIH does offer some funding support to plant biology research,
    with increased funding plant biologists can offer much more to advance
    the missions of NIH. In the next section, we highlight the particular
    relevance of plant biology research to human health.
    Plant Biology and 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.'' 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, and the
    molecular mechanisms employed by both the pathogen and its targeted
    host can be very similar.
    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. Indeed, one World Health Organization 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 common illnesses
    such as respiratory infections and diarrhea. 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, and the
    lycopenes found in tomato. Ongoing development of crop varieties with
    tailored nutraceutical content is an important contribution that plant
    biologists are making toward realizing the goal of personalized
    medicine, especially personalized preventative medicine.
    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 World Health Organization 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 anti-malarial 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
    isolated and named taxol after the tree's Latin name, Taxus brevifolia.
    Originally, taxol could only be obtained from the tree bark itself, but
    additional research led to the elucidation 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 of Tropical Medicine and
                                    Hygiene

        The American Society of Tropical Medicine and Hygiene (ASTMH)--the
    principal professional membership organization representing, educating,
    and supporting scientists, physicians, clinicians, researchers,
    epidemiologists, and other health professionals dedicated to the
    prevention and control of tropical diseases--appreciates the
    opportunity to submit written testimony to the Senate Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations
    Subcommittee. We respectfully request that the subcommittee provide the
    following allocations in the fiscal year 2011 Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill to
    support a comprehensive effort to promote malaria, neglected tropical
    disease (NTD), and diarrheal disease control programming globally:
      --$35 billion to the National Institutes of Health (NIH);
      --$5.04 billion to the National Institute of Allergy and Infectious
            Diseases (NIAID);
      --$78.5 million to the Fogarty International Center (FIC);
      --$18 million to the Centers for Disease Control and Prevention (CDC)
            for malaria research, control, and program evaluation efforts
            with a $6 million set-aside for program monitoring and
            evaluation; and
      --Direct funding to the CDC for ongoing efforts on NTDs and diarrheal
            disease.
    ASTMH Background
        The 3,700 members of ASTMH work in a myriad of public, private, and
    nonprofit environments. The largest proportion of our membership (34
    percent) work in academia at the Nation's leading research
    universities. Fifteen percent of ASTMH members are employed by the U.S.
    military, and 11 percent are employed in public institutions and
    Federal agencies. Nine percent of ASTMH members are in private
    practice, with another 4 percent working in industry (e.g.,
    pharmaceutical companies). The balance of the ASTMH membership works in
    numerous other capacities and for various other entities seeking to
    reduce and prevent tropical disease.
    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 vector borne 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.
        ASTMH aims to advance policies and programs that prevent and
    control those tropical diseases which particularly impact the global
    poor. The United States has a long history of leading the fight against
    tropical diseases which cause human suffering and pose a great
    financial burden that can negatively impact a country's economic and
    political stability. The benefits of U.S. investment in tropical
    diseases are not only humanitarian, they are diplomatic as well. ASTMH
    members and others work to reduce the impact of tropical diseases and
    to directly and positively impact populations that are otherwise
    generally ignored, but on whom many countries' futures depend. Tropical
    diseases, many of them neglected for decades, impact U.S. citizens
    working or traveling overseas as well as our military personnel.
    Furthermore, some of the agents responsible for these diseases can be
    introduced and become established in the United States (as was the case
    with West Nile virus), or might even be weaponized.
    Malaria
        Malaria remains a global emergency affecting mostly poor women and
    children; it is an acute, sometimes fatal disease caused by the single-
    celled Plasmodium parasite transmitted to humans by Anopheles
    mosquitoes. 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. Approximately every 30
    seconds, a child dies of malaria--a total of about 800,000 under the
    age of 5 every year. (During the time it took to read this message, 10
    children have died.)
        The World Health Organization (WHO) estimates that one-half of the
    world's people are at risk for malaria and that there are 108 malaria-
    endemic countries. Malaria-related illness and mortality not only take
    a human toll, they 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) the indoor residual
    spraying (IRS) of insecticide on the walls of homes; (2) long-lasting
    insecticide-treated nets (LLIN); (3) Artemisinin-based combination
    therapies (ACTs); and (4) intermittent preventive therapy (IPT) for
    pregnant women in areas with high transmission. However, limited
    resources preclude the provision of these interventions and treatments
    to all individuals and communities in need. Thus, ASTMH calls upon
    Congress to fund a comprehensive approach to malaria control, including
    public health infrastructure improvements, mosquito abatement
    initiatives, and increased availability of existing anti-malarial
    drugs, development of new anti-malarial drugs and better diagnostics,
    and research to identify an effective malaria vaccine.
    Neglected Tropical Diseases, Diarrheal Disease and Arboviruses
        According to WHO, more than 1 billion people--one-sixth of the
    world's population--suffer from one or more NTDs, including arboviruses
    such as yellow fever and Dengue fever. The pediatric death toll due to
    diarrheal illnesses exceeds that of AIDS, tuberculosis, and malaria
    combined. In poor countries, diarrheal disease is second only to
    pneumonia in causing the deaths of children under 5 years old. Every
    week, 31,000 children in low-income countries die from diarrheal
    diseases. Diarrheal and NTDs, including arboviruses, are a symptom of
    poverty and disadvantage. Most of those affected are the poor
    populations in rural areas, urban slums or conflict zones.
    Traditionally, these diseases have been neglected by the world.
    Requested Activities and Funding Levels
        NIAID.--Malaria continues to be among the most daunting global
    public health challenges we face and one-sixth of the world's
    population suffers from one or more NTDs. A long-term investment is
    needed to achieve the drugs, diagnostics and research capacity needed
    to control malaria and neglected tropical disease. NIAID, the lead
    institute for malaria research, plays an important role in developing
    the drugs and vaccines needed to fight malaria.
        Malaria.--NIH estimates spending approximately $152 million overall
    with for malaria research and $36 million for research related
    specifically to creating a malaria vaccine in fiscal year 2011. NIAID,
    the lead Institute for this research, has developed an Implementation
    Plan for Global Research on Malaria, which is focused on five research
    areas: vaccine development, drug development, diagnostics, vector
    control, and infrastructure and research capability strengthening.
        NTDs.--The NIH, through NIAID conducts research to better
    understand NTDs, which includes conducting its own basic and clinical
    studies as well as extramural research. These efforts include:
      --Research at the NIAID Laboratory of Parasitic Diseases to uncover
            how NTD-causing pathogens interact with humans, animals, and
            the organisms that spread them from host to host. The lab
            conducts patient-centered research at the NIH Clinical Center
            in Bethesda, MD, as well as field studies in India, Latin
            America, and Africa.
      --Actively supporting the discovery and development of drugs for NTDs
            including a low-cost treatment for visceral leishmaniasis and
            identifying new drugs for sleeping sickness and Chagas disease.
      --The Vector Biology Research Program at NIAID supports research on
            several vectors that transmit agents of NTDs. Many of these
            projects have field components in disease-endemic areas of the
            world.
      --NIAID also has research repositories that provide researchers with
            parasite species, standard study protocols, and training.
        ASTMH encourages NIH to continue and expand its investment in
    malaria, NTD, diarrheal disease, and arbovirus research and to
    coordinate that work with other Government agencies to maximize
    resources and ensure development of basic discoveries into useable
    solutions. NIAID is at the forefront of these efforts and continued
    funding is crucial to developing the next generation of drugs,
    vaccines, and other interventions.
        FIC.--Although biomedical research has provided major advances in
    the treatment and prevention of malaria, neglected tropical diseases
    and other infectious diseases, 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. For example, for
    nearly a decade FIC has funded a program that has produced a
    substantial number of researchers with the expertise to address the
    research and clinical challenges associated with diarrheal diseases in
    Latin America. This strong international collaboration is fostering new
    discoveries on the long-term effects of and treatments for diarrheal
    diseases. By promoting applied health research in developing countries,
    the FIC can speed the implementation of new health interventions for
    malaria and NTDs.
        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 many 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, 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 2011 to increase these efforts, particularly as
    they address the control and treatment of malaria, NTDs, and diarrheal
    disease.
        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.
        The CDC is crucial partner in the President's Malaria Initiative
    (PMI), a $6.2 billion, 9-year effort led by the U.S. Agency for
    International Development (USAID) 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.
        CDC efforts on malaria fall into three broad areas--prevention,
    treatment, and monitoring/evaluation. The agency performs a wide range
    of basic research within these categories, such as:
      --Providing technical assistance to malaria-endemic, non-PMI
            countries;
      --Conducting research on LLINs, IRS, malaria in pregnancy, and case
            management including diagnosis, treatment and antimalarial drug
            resistance to inform new strategies and prevention approaches;
      --Assessing new monitoring, evaluation and surveillance strategies;
      --Conducting additional research on malaria vaccines, including field
            evaluations; and
      --Developing novel public health strategies for improving access to
            antimalarial treatment and delaying the appearance of
            antimalarial drug resistance.
        CDC NTD Programs.--CDC has had a long history of working on NTDs
    and has provided much of the science that underlies those global
    policies and programs in existence today. ASTMH encourages the
    Subcommittee to provide direct funding to the CDC to continue its work
    on NTDs, diarrheal diseases, and arboviruses, such as Japanese
    encephalitis and Dengue. This work is important to any global health
    initiative as individuals are often infected with multiple NTDs
    simultaneously. It is essential that CDC be encouraged to continue its
    monitoring, evaluation and technical assistance in these areas as an
    underpinning of efforts to control and eliminate these diseases.
    Currently the CDC receives zero dollars directly for NTD work; however
    this should be changed to allow for more comprehensive work to be done
    on NTDs directly at the CDC.
    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 2011
    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

                        SUMMARY: FUNDING RECOMMENDATIONS
                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                  Amount
    ------------------------------------------------------------------------
    National Institutes of Health..........................         35,000
        National Heart, Lung & Blood Institute.............          3,514
        National Institute of Allergy and Infectious                 5,395
         Disease...........................................
        National Institute of Environmental Health Sciences            779.4
        Fogarty International Center.......................             78.4
        National Institute of Nursing Research.............            163
    Centers for Disease Control and Prevention.............          8,800
        National Institute for Occupational Safety and                 364.3
         Health............................................
        Asthma Programs....................................             70
        Division of Tuberculosis Elimination...............            220.5
        Chronic Disease Prevention and Health Promotion:                 3
         COPD..............................................
        Office on Smoking and Health.......................            280
        National Sleep Awareness Roundtable................              1
    ------------------------------------------------------------------------

        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. Founded in 1905, the ATS is an international education and
    scientific society that focuses on respiratory and critical care
    medicine. The ATS's 18,000 members help prevent and fight respiratory
    disease through research, education, patient care, and advocacy.

                            LUNG DISEASE IN AMERICA

        Diseases of breathing constitute the third-leading cause of death
    in the United States, responsible for 1 of every 7 deaths. Diseases
    affecting the respiratory (breathing) system include chronic
    obstructive pulmonary disease (COPD), lung cancer, tuberculosis (TB),
    influenza, sleep-disordered breathing, pediatric lung disorders,
    occupational lung disease, sarcoidosis, asthma, and critical illness.
    The death rate due to 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.
        In recognition of the rising global burden of lung disease and the
    need for increased awareness and action to promote lung health, the
    ATS, in conjunction with the Federation of International Respiratory
    Societies, has declared 2010 to be the Year of the Lung. Throughout
    2010, the ATS will be sponsoring a series of congressional briefings
    and other events to raise lung disease awareness.
    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.
    This funding has sustained NIH support for groundbreaking research into
    diseases like COPD and asthma that affect millions of Americans. It is
    critical that this reinvestment in biomedical research is reinforced
    through annual budget increases that permit the NIH to respond to
    public health needs. We ask the subcommittee to provide $35 billion in
    funding for the NIH in fiscal year 2011.
        Despite the rising lung disease burden, lung disease research is
    underfunded. In fiscal year 2009, 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 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.
    Centers for Disease Control and Prevention (CDC)
        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 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 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 $8.8
    billion for the CDC in fiscal year 2011.
    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 limitation in breathing due mainly to emphysema and chronic
    bronchitis. CDC estimates that 12 million patients have COPD; an
    additional 12 million Americans are unaware that they have this life
    threatening disease.
        The ATS feels that resources committed to COPD for research and
    education are not commensurate with the impact the disease has on
    Americans. 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 COPD Education and Prevention Program.
        CDC also has a role to play in this work. To address the increasing
    public health burden of COPD, we encourage the creation of a CDC COPD
    program at the Center for Chronic Disease Prevention and Health
    Promotion, and request an appropriation of $3 million in fiscal year
    2011 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, and that the CDC be encouraged to add COPD-based questions to
    future CDC health surveys, including the National Health and Nutrition
    Evaluation Survey, the National Health Information Survey, and the
    Behavioral Risk Factor Surveillance Survey.

                                TOBACCO CONTROL

        Cigarette smoking is the leading preventable cause of death in the
    United States, responsible for 1 in 5 deaths annually. The ATS
    congratulates the President and the Congress for enactment of the
    Family Smoking and Tobacco Prevention Act. The CDC's Office of Smoking
    and Health coordinates public health efforts to reduce tobacco use. In
    order to significantly reduce tobacco use within 5 years, as
    recommended by the subcommittee in fiscal year 2010, the ATS recommends
    $280 million in funding for the Office of Smoking and Health in fiscal
    year 2011.

                             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. In 2006, about 1 in 5 deaths in children under 1
    year of age was due to a lung disease. 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, including 7
    million children. 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. The
    ATS recommends an fiscal year 2011 funding level of $70 million for the
    CDC's asthma program.

                                     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-disordered breathing and sleep-related
    illnesses affect an estimated 50-70 million Americans. The public
    health impact of sleep illnesses and sleep disordered breathing is
    still being determined, but is known to include increased mortality,
    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 $1 million in fiscal year 2011 to
    support activities related to sleep and sleep disorders at the CDC,
    including for the National Sleep Awareness Roundtable, 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 at the NHLBI.

                               TUBERCULOSIS (TB)

        TB is the second-leading global infectious disease killer, claiming
    1.8 million lives each year. It is estimated that 9-14 million
    Americans have latent TB. 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 TB range from $100,000 to $300,000. The global TB
    pandemic and spread of drug resistant TB present a persistent public
    health threat to the United States.
        Despite declining 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 occur,
    outstripping local capacity; (4) continued emergence of drug
    resistance; and (5) there are critical needs for new diagnostics,
    treatment, and prevention tools.
        In 2008, Congress passed the Comprehensive Tuberculosis Elimination
    Act (CTEA, Public Law 110-392). This historic legislation 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 also authorizes an
    urgently needed reinvestment into new TB diagnostic, treatment and
    prevention tools. The ATS, recommends a funding level of $220.5 million
    in fiscal year 2011 for CDC's Division of TB Elimination, as authorized
    under the CTEA, and encourages the NIH to expand efforts, as requested
    under the CTEA, to develop new tools to reduce the rising global TB
    burden.

                                 CRITICAL CARE

        The burden associated with provision of care to critically ill
    patients is enormous, and is anticipated to increase significantly as
    the population ages. Investigation into diagnosis, treatment, and
    outcomes in critically ill patients should be a high priority, and the
    NIH should be encouraged and funded to coordinate investigation related
    to critical illness in order to meet this growing national imperative.

                          FOGARTY INTERNATIONAL CENTER

        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
    professionals in TB treatment and research. These training grants
    should be expanded and offered to all institutions. The ATS recommends
    Congress provide $78.4 million for FIC in fiscal year 2011, to allow
    expansion of 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 $364.3 million in fiscal year
    2011 for NIOSH to expand or establish the following activities: the
    National Occupational Research Agenda; 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. 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 Animal Welfare Institute

        As part of the fiscal year 2010 appropriations bill for the
    National Institutes of Health (NIH), both the Senate and the House of
    Representatives included language in their reports directing NIH to
    take steps to end the use of Class B dealers by its grant recipients.
    Grantees affected by this language are small in number. According to
    USDA, for the period November 2007-November 2008, 2,863 dogs and 276
    cats came from Class B dealers. This constitutes just 3 percent of the
    almost 95,000 total dogs and cats used in fiscal year 2007 for all
    research purposes, which include not only NIH-sponsored research, but
    also non-NIH-related research, testing and teaching.
        Both chambers were responding to a report from the National Academy
    of Sciences (NAS) (``Scientific and Humane Issues in the Use of Random
    Source Dogs and Cats in Research''), undertaken at the request of
    Congress, that ``critically examine[d] the general desirability and
    necessity of using random source dogs and cats in NIH-funded research,
    and the specific necessity of using Class B dealers as a source of such
    animals for NIH-funded research.'' (p. 2) While the Committee
    ``concluded that under some circumstances, dogs and cats with qualities
    of random source animals may be desirable and necessary for NIH-funded
    research,'' it also ``determined Class B dealers are not necessary as
    providers of random source animals for NIH-related research'' (p. 5)
    and that adequate numbers of such animals are available from other
    sources. Acknowledging this finding, the Senate Appropriations
    Committee said, in part, that it ``expects the NIH to phase out, as
    quickly as possible, the use of any of its funds 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 . . . and resell
    them. Specifically, the NIH should not award any new grants or
    contracts that involve such animals and should immediately begin
    supporting alternative sources of random source animals from non-class
    B dealers.''
        NIH has been dragging its feet in addressing the problem of Class B
    dealers for a decade, since Congress first expressed its concern over
    the matter. Based on statements NIH representatives have made with
    respect to the NAS report and the appropriations report language, we
    expect them to continue dragging their feet. We respectfully request
    that the subcommittee follow up the strong, sound position it laid out
    in the report language with statutory language prohibiting NIH from
    awarding or renewing any grants or contracts that involve the use of
    dogs or cats acquired from class B dealers, and that, moreover, NIH
    immediately begin supporting alternative sources of random-source dogs
    and cats from non-Class B dealers.
        It should be clarified that the NAS report addressed extramural
    research funded by NIH, not NIH's internal research endeavors. The
    irony is, NIH ceased using Class B dealers in its own intramural
    research over 20 years ago, recognizing the problems--both ethical and
    scientific--caused by acquiring dogs from sources that treat the
    animals inhumanely; fail to provide proper veterinary care and the
    basic necessities such as clean water, food, and shelter; acquire
    animals through fraud and deception; and are constantly under
    investigation for violations of the Animal Welfare Act (AWA). In fact,
    in a recent article in Science (David Grimm, ``Dog Dealers' Days May Be
    Numbered,'' Vol. 327, 26 February 2010, p. 1076-1077), Dr. Robert
    Whitney, former director of NIH's National Center for Research
    Resources (1972-1992) and Deputy Surgeon General of the U.S. Public
    Health Service (1992), is quoted as saying, ``By using these animals,
    we risk losing our credibility with the public. It's an Achilles' heel
    for research.'' Even so, NIH steadfastly refuses to hold its extramural
    grant recipients to the same high standard it requires of its
    intramural researchers.
        Of the 10 remaining licensed Class B dealers who sell live random
    source dogs and cats for experimentation, one is presently under a 5-
    year license suspension, and 6 are under investigation for AWA
    violations. And welfare problems with licensed Class B dealers are
    myriad. Needed veterinary care is lacking for many random source
    animals. Heartworm is a widespread problem, particularly in the South.
    Hookworm and mange are as well. Inspectors have observed animals at
    dealer premises with mange, ``loose stool with some blood,'' ``ring-
    worm like lesions,'' infected eyes, bite wounds, lameness, tumors,
    chronic cough, and animals who are severely underweight and others with
    a ``purulent discharge from the nose.'' In most cases, there is no
    record of any veterinary care.
        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 to see if there will be a taker. If
    not, the animal may be taken back and left to die or simply 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 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 non-potable water. Water was mixed with bread and dog food and
    sitting in the direct sun.''
        The NAS report took note of these failures to provide for the
    animals' basic welfare: ``In addition, the Committee determined that
    the husbandry standards and humane treatment of animals was
    unacceptably variable among existing Class B dealers, and not
    commensurate with NIH standards of research animal care and quality.''
    (p. 86; emphasis added.) The report also observed that ``random source
    dogs and cats used for research probably endure greater degrees of
    stress and distress compared to purpose-bred animals. This conclusion
    has implications not only for the welfare of random source animals but
    also for their overall reliability as research models.'' (p. 59)
        USDA is also pursuing separate investigations regarding apparent
    supply violations identified during tracebacks conducted of dealer
    records necessitated by ongoing questions about the illegality of the
    sources of animals. Unlike any other licensees covered under the AWA,
    this one group--Class B dealers selling dogs and cats for research--has
    a long-standing problem maintaining complete and accurate records. 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?
        Complicating matters further is the fact that dealers commonly
    network with each other; that is, animals are sold from buncher (an
    unlicensed dealer who literally bunches together animals from various
    sources) to dealer to another dealer, often across multiple State
    lines, before being sold for research. With animals changing hands and
    being shipped across the country, how is USDA supposed to keep up with
    the movement of animals and verify their source?
        Another shell game dealers like to play is passing the business on
    to other members of the family after 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. Brothers Danny
    and Johnny Schachtele of Missouri ran their licensed Class B dealer
    operation as a team beginning in 1987. Later Johnny left the business
    and Danny's wife, Mildred, replaced him. Over the ensuing years, the
    husband-wife team were cited by USDA for a host of violations of the
    AWA, 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. But 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. Becky and Tony
    Schachtele have been cited repeatedly by USDA for apparent violations
    including inadequate veterinary care, faulty recordkeeping, inadequate
    cleaning and sanitization and problems with housing and primary
    enclosures. Among multiple dogs in need of veterinary care, the USDA
    inspector noted one dog ``standing with its head down and rocking in an
    abnormal manner from front to back and side to side . . . dull eyes . .
    . never lifted its head . . . was very thin with very prominent, easily
    visible bony structures . . . the dogs abdomen was extremely tucked and
    its hair coat was dull.'' At one inspection alone, 48 records had
    incomplete addresses for the persons who sold the animals; 31 animal
    certification forms were incomplete; and 44 forms had inconsistent and
    therefore inaccurate information regarding the animals and when they
    were acquired and sold. Though under investigation, the Schachteles are
    still selling dogs and cats for research.
        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.'' To
    address these numerous and ongoing violations, USDA has to inspect
    random source dealers four times a year instead of once a year as is
    done with all other licensees and registrants under the AWA. It spends
    approximately $300,000 per year trying to regulate this small number of
    dealers, and even with that, the department acknowledged in its NAS
    testimony that it cannot guarantee that stolen pets are not being sold
    into research.
        The effect on the animals of such inhumane treatment, and the costs
    of enforcement, are not included in the calculation when NIH cites the
    cheaper cost of random source dogs and cats acquired from Class B
    dealers. But the NAS report does take this into account: ``. . .
    [O]ftentimes dogs and cats from Class B dealers are not free from
    disease. In addition to being a potential threat to other animals and
    people in the research facility, they may need to undergo prolonged
    quarantine, socialization, treatment, or be removed from the study all
    together [sic]. These hidden costs may substantially increase the
    actual final cost by hundreds of dollars per animals. Additionally, the
    price of USDA/APHIS oversight of Class B dealers . . . represents a
    substantial cost to the U.S. government and ultimately the American
    public that is not incurred by NIH, the research institution, nor the
    research investigator.'' (p.75)
        The AWA was passed in 1966 to address the illegal supply of dogs
    and cats to laboratories, and now, over four decades later, these
    problems are still widespread. What has changed significantly over this
    lengthy period of time is the availability of animals from suppliers
    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, with the health and vaccination status and the genetic
    background on each individual animal 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 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.'' The
    National Academies report clearly states that ``it is not necessary to
    acquire them [random source dogs and cats] through Class B dealers,''
    (``Report In Brief''), and that adequate numbers are available through
    alternative sources.
        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 involves illegal acquisition of animals, fraudulent or
    incomplete records and other illicit activities, and failure to abide
    by the minimum care requirements of the AWA.
        Thank you very much for your consideration of our request for
    statutory language to address this issue and put an end to wasting
    taxpayer money on propping up this corrupt system.
                                     ______

     Prepared Statement of the Building and Construction Trades Department
                                    AFL-CIO

        My name is Erich (Pete) Stafford and I am the Director of Safety
    and Health for the Building and Construction Trades Dept (BCTD) AFL-
    CIO. The BCTD is composed of 13 international unions representing some
    3 million members employed in the building and construction industry.
        The purpose of this testimony is to request your support for
    increased funding for the National Institute for Occupational Safety
    and Health (NIOSH), and its construction research program.
        Despite improvements in workplace safety and health, nearly 15
    American workers die each day from injuries sustained at work, and 134
    die from work-related diseases. Of those killed every day, nearly 4
    work in the construction industry.
        Indeed, construction has the dubious distinction of being the
    single most hazardous industry in the United States accounting for some
    1,200 construction workers killed on the job each year. (see attached
    chart). Another 150,000 suffer serious injuries requiring time off from
    work. Moreover, due to exposures to an array of toxic and hazardous
    substances, construction workers have unacceptably high levels of
    occupational disease including cancers, silicosis, asbestosis, and
    other heart, lung and neurological diseases.
        While construction workers make up only 8 percent of the U.S.
    workforce, they account for more than 22 percent of all work-related
    deaths. The number of construction workers killed on the job is 10
    times the number of firefighters and law enforcement officers killed in
    the line of duty each year, and 20 times the number of job-related
    deaths to miners.
        In addition to the human tragedy, the economic costs are
    staggering. The total cost of fatal and nonfatal injuries and disease
    in the construction industry has been estimated at nearly $13 billion
    annually. And, that does not count the costs of workers' compensation,
    which, at $30 billion a year, are twice that of manufacturing and three
    times that for all industries.
        NIOSH, is the only Federal agency responsible for conducting
    research and making recommendations for the prevention of work-related
    injury and illness. Yet it is one of the most under funded health
    research agencies in the Federal Government, and is hamstrung by being
    buried in the bowels of the Centers for Disease Control and Prevention
    bureaucracy where it remains an orphan.
        Except for a special $80 million increase for the World Trade
    Center (WTC) health program and some $7 million for nanotechnology
    research, the President's fiscal year 2011 NIOSH budget request remains
    at last year's level. While we support both the WTC and nanotechnology
    programs, we think it's high time for the Congress to review the entire
    NIOSH program with an eye towards dramatically improving both its
    structural place within the Department of HHS and its funding.
        With respect to funding, especially funding for the NIOSH National
    Occupational Research Agenda (NORA) program, we recommend a $25 million
    increase more than the President's static $124.5 million NORA request.
    This would permit a modest expansion of NIOSH/NORA research activities
    beyond nanotechnology.
        We are particularly concerned with NORA funding for the
    ``construction initiative'' that seeks to (1) identify safety and
    health problem areas and obstacles to prevention and (2) translate that
    research into practice via partnerships and field studies across a
    variety of construction trades.
        A recent National Academy of Sciences' Institute of Medicine review
    of the NIOSH construction program, recommended:
      --Increased funding for the program.
      --Strengthening NIOSH's internal management of the program.
      --Retaining ``The National Construction Center'' as the main focus
            for ``research to practice'' (R2P) activities.
        According to the National Academy: ``Total annual funding for the
    Construction Research Program between fiscal year 1997 and fiscal year
    2007 has averaged about $17.8 million, ranging from a high of $20.3
    million in fiscal year 1997 to a low of $13.8 million in fiscal year
    2007. . . . When adjusted for inflation and changes in technologies,
    the funding level for the program has declined in terms of real
    purchasing power . . .''
        Moreover, the study committee concluded ``. . . that in spite of
    budget constraints, the Construction Research Program has made an
    impact on one of the most dangerous and largest of U.S. industries. The
    committee finds the funding level inadequate and recommends that high-
    level attention be given to determining how to provide program
    resources that are commensurate with a more robust pursuit of the
    program's goals . . .''
        Given the research agenda outlined and recommended by the NAS
    Review Committee, we believe that the construction program should be
    placed on a sounder financial footing and recommend that it receive
    additional funds from the $25 million NIOSH/NORA budget increase we
    have requested.
        To address the many construction safety and problems in our
    industry, the BCTD research arm--The Center for Construction Research
    and Training (CPWR)--has, for many years, been working with NIOSH
    through the NORA construction research initiative. The CPWR was
    recently awarded another 5-year extension of its NIOSH contract to
    serve as the ``National Construction Center'' to coordinate the
    ``Research to Practice'' program. Unfortunately, funding for the
    ``National Construction Center'' has remained flat for the past 15
    years at about $5 million annually.
        We strongly believe that the best way to address what has become a
    safety and health crisis in our industry is through targeted and
    applied research to better understand the causes of construction-
    related incidents and illness and find ways implement solutions on U.S.
    construction sites. While there is certainly an additional need for
    better standards and enforcement by the Department of Labor, NIOSH
    construction research is the critical first step towards a safer and
    healthier construction workforce.
        In addition to fostering more investigator-initiated extramural
    research into risks from emerging technologies such as nano-particles
    and strengthening NIOSH administration, a modest increase in funding
    would expand the transfer of research-to-practice functions of the
    National Construction Center with special emphasis on:
      --Social marketing outreach to small-to-medium sized (less than 50
            employees) workplaces
      --Special worker populations including immigrant, minority, young and
            older workers.
      --Opportunities to combine safety and health with more energy-
            efficient construction practices and investigate emerging
            hazards in green construction.
        As you consider the fiscal year 2011 Labor, Health and Human
    Services, and Education, and Related Agencies appropriation bill, we
    urge you to take some time to consider the safety and health of our
    building and construction workforce. The current situation is simply
    unacceptable and, in light of demands for increased public spending for
    construction projects to stimulate the economy, the safety and health
    pressures on our workers will only become more intense.
        Thank you.

                                      FACILITIES IN THE U.S. CONSTRUCTION INDUSTRY
    ----------------------------------------------------------------------------------------------------------------
                                           2003            2004            2005            2006            2007
    ----------------------------------------------------------------------------------------------------------------
    Construction....................           1,171           1,278           1,243           1,297           1,239
    Transportation..................            >800           >800+            >800            <900            <900
    Manufacturing...................            >400            >400            <400            >400             400
    Agriculture.....................            >700            >600            >700            >600             600
    Mining..........................           >100+            >100            >100             200            <200
    ----------------------------------------------------------------------------------------------------------------
    Source: Center for Construction Research and Training.

                          SAFETY AND HEALTH FACTS \1\
    ---------------------------------------------------------------------------
        \1\ Source: Center for Construction Research and Training.
    ---------------------------------------------------------------------------
        The construction industry employs only 8 percent of the workforce
    but it suffers 22 percent of all work-related deaths.
        Low-skilled, low-paid laborers suffer the most fatalities.
        Construction establishments with less than 20 workers account for
    55 percent of all fatalities.
        Lung cancer deaths are 50 percent higher among construction workers
    than the U.S. population, adjusted for smoking.
        Construction workers are twice as likely to have chronic
    obstructive lung diseases.
        Construction workers are five times as likely to have a cancer of
    the lung lining, mesothelioma, and 33 times as likely to have
    asbestosis, an incurable and fatal lung disease.
        30-40 percent of construction workers suffer musculoskeletal
    disorders and chronic pain.
        50 percent of construction workers have noise-induced hearing loss.
        Construction workers account for 17 percent of workers with
    elevated blood lead levels.
        Welding fumes account for 75 percent of boilermakers, 15 percent of
    ironworkers and 7 percent of pipefitters exceed the accepted 8-hour
    level for manganese exposure; a known neurotoxin.
                                     ______

              Letter From the Brain Injury Association of America
                                                         April 7, 2010.
    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 Chairman Harkin and Ranking Member Cochran: Thank you for the
    opportunity to submit this written testimony with regard to the fiscal
    year 2011 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.
        Recently, we are seeing an increasing number of service members
    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 traumatic brain injury
    during deployment. Many of these returning service members 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 13 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 brain injury. 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:
      --$10 million (+$4 million) for the Centers for Disease Control and
            Prevention TBI Registries and Surveillance, Brain Injury Acute
            Care Guidelines, Prevention and National Public Education/
            Awareness
      --$8 million (+$1 million) for the Health Resources and Services
            Administration (HRSA) Federal TBI State Grant Program
      --$4 million (+$1 million) for the HRSA Federal TBI Protection &
            Advocacy (P&A) Systems Grant Program
        CDC--National Injury Center.--The Centers for Disease Control and
    Prevention's National Injury Center is responsible for assessing the
    incidence and prevalence of TBI in the United States. The CDC estimates
    that 1.4 million TBIs occur each year and 3.4 million Americans live
    with a life-long disability as a result of TBI. In addition, the TBI
    Act as amended in 2008 requires the CDC to coordinate with the
    Departments of Defense and Veterans Affairs to include the number of
    TBIs occurring in the military. This coordination will likely increase
    CDC's estimate of the number of Americans sustaining TBI and living
    with the consequences.
        CDC also funds States for TBI registries, creates and disseminates
    public and professional educational materials, for families, caregivers
    and medical personnel, and has recently collaborated with the National
    Football League and National Hockey League to improve awareness of the
    incidence of concussion in sports. CDC plays a leading role in helping
    standardize evidence based guidelines for the management of TBI and $3
    million of this request would go to fund CDC's work in this area as
    well as support a pilot project to improve hospital compliance with
    existing guidelines.
        HRSA TBI State Grant Program.--The TBI Act authorizes the HHS,
    Health Resources and Service Administration (HRSA) to award grants to
    (1) States, American Indian Consortia and territories to improve access
    to service delivery and to (2) State Protection and Advocacy (P&A)
    Systems to expand advocacy services to include individuals with
    traumatic brain injury. For the past 13 years the HRSA Federal TBI
    State Grant Program has supported State efforts to address the needs of
    persons with brain injury 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 brain injury care.
        Increasing the program to $8 million will provide funding necessary
    to sustain the grants for the 15 States currently receiving funding
    along with the three additional States added this year and to ensure
    funding for four additional States. Steady increases over 5 years for
    this program will provide for each State including the District of
    Columbia and the American Indian Consortium and territories 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.
        HRSA TBI P&A Program.--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, information, and referral 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
    traumatic brain injury is needed to help reduce government expenditures
    and increase productivity, independence and community integration.
    However, advocates must possess specialized skills, and their work is
    often time-intensive. A $4 million appropriation would ensure that each
    P&A can move towards providing a significant PATBI program with
    appropriate staff time and expertise.
        National Institute on Disability and Rehabilitation Research
    (NIDRR) TBI Model Systems of Care.--Funding for the TBI Model Systems
    in the Department of Education 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 brain injury. 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 $11 million (+$1.5 million) in fiscal year 2011 for NIDRR's TBI
    Model Systems of Care program, in order to add one new Collaborative
    Research Project. In addition, given the national importance of this
    research program, the TBI Model Systems of Care should receive ``line-
    item'' status within the broader NIDRR budget.
        We ask that you consider favorably these requests for the CDC, the
    HRSA Federal TBI Program, and the NIDRR TBI Model Systems Program to
    further data collection, increase public awareness, improve medical
    care, assist States in coordinating services, protect the rights of
    persons with TBI, and bolster vital research.
                Sincerely,
                                      Susan H. Connors,
                                                 President/CEO,
                                   Brain Injury Association of America.
                                     ______

                   Prepared Statement of the CAEAR Coalition

        On behalf of the tens of thousands of individuals living with HIV/
    AIDS to whom the members of the Communities Advocating Emergency AIDS
    Relief (CAEAR) Coalition provide care, I want to thank Chairman Tom
    Harkin and Ranking Member Thad Cochran for affording CAEAR Coalition
    the opportunity to submit this written testimony for the record
    regarding increased funding for the Ryan White HIV/AIDS Program.
        CAEAR Coalition is a national membership organization which
    advocates for Federal appropriations, legislation, policy and
    regulations to meet the care, treatment, support service, and
    prevention needs of people living with HIV/AIDS and the organizations
    that serve them. CAEAR Coalition's proactive national leadership is
    focused on the Ryan White Program as a central part of the Nation's
    response to HIV/AIDS. CAEAR Coalition's members include Ryan White
    Program part A, part B, and part C consumers, grantees, and providers.
    A Wise Investment in a Program That Works
        The Ryan White Program works. Those on the epidemic's frontlines
    know this to be true, and that faith received a ringing endorsement
    from the White House Office of Management and Budget (OMB). In its 2007
    Program Assessment Rating Tool (PART), OMB gave the Ryan White Program
    its highest possible rating of ``effective''--a distinction shared by
    only 18 percent of all programs rated. According to OMB, effective
    programs ``set ambitious goals, achieve results, are well-managed and
    improve efficiency.'' Even more impressively, OMB's assessment of the
    Ryan White Program found it to be in the top 1 percent of all Federal
    programs in the area of ``Program Results and Accountability.'' Out of
    the 1,016 Federal programs rated--98 percent of all Federal programs--
    the Ryan White Program was one of seven that received a score of 100
    percent in ``Program Results and Accountability.''
        The reauthorization of the Ryan White Program signed in October
    2009 was a tremendous victory for people living with HIV/AIDS and those
    who care for them. We are grateful for congressional efforts to ensure
    that this vital program continued uninterrupted when it expired in
    September. As you are aware, the Ryan White Program serves as the
    indispensable safety net for thousands of low-income, uninsured, or
    underinsured people living with HIV/AIDS.
      --Part A provides much-needed funding to the 56 major metropolitan
            areas hardest hit by the HIV/AIDS epidemic with severe needs
            for additional resources to serve those living in their
            communities.
      --Part B assists States and territories in improving the quality,
            availability, and organization of healthcare and support
            services for individuals and families with HIV disease.
      --The AIDS Drug Assistance Program (ADAP) in part B provides urgently
            needed medications to people living with HIV/AIDS in all 50
            States and the territories.
      --Part C provides grants to 357 faith- and community-based primary
            care health clinics and public health providers in 49 States,
            Puerto Rico and the District of Columbia. These clinics play a
            central role in the delivery of HIV-related medical services to
            underserved communities, people of color, and rural areas.
      --Part F AETC supports training for healthcare providers to identify,
            counsel, diagnose, treat, and manage individuals with HIV
            infection and to help prevent high-risk behaviors that lead to
            infection. It has 130 program sites in all 50 States.
        We thank you in advance for your consideration of our comments and
    our request for:
      --$905 million for part A to support grants to the cities hardest hit
            by HIV/AIDS so they can provide quality care to people with
            HIV/AIDS (an increase of $225.9 million);
      --$474.7 million for part B base to provide additional needed
            resources to the States in their efforts to address the HIV/
            AIDS epidemic (an increase of $55.9 million).
      --$1,205.1 million in funding for the ADAP line item in part B so
            uninsured and underinsured people with HIV/AIDS can access the
            prescribed medications they need to survive (an increase of
            $307.1 million).
      --$337.8 million for part C to support grants to community-based
            organizations, agencies, and clinics that provide quality care
            to people living with HIV/AIDS (an increase of $131 million).
      --$50 million to fund the 11 regional centers funded under by part F
            AETC to offer specialized clinical education and consultation
            on HIV/AIDS transmission, treatment, and prevention to
            frontline healthcare providers (an increase of $15.9 million).
        The increases CAEAR Coalition seeks in the current funding for part
    A, part B base and ADAP, part C, and part F AETC reflect the reality
    that the HIV/AIDS epidemic and the healthcare and social service needs
    of people with HIV/AIDS require significantly more Federal resources
    than those provided in recent years. There continues to be an ever-
    growing gap between the number of people living with AIDS in the United
    States in need of care and the resources available to serve them. For
    example, between 2001 and 2007 the number of people living with AIDS
    grew 33 percent and yet funding for medical care and support services
    in the Nation's hardest hit communities grew less than 12 percent
    between 2001 and 2010. Similarly, funding for part C-funded, community-
    based primary care clinics, which provided medical care for people
    living with HIV/AIDS in rural and urban communities nationwide, grew by
    only 11 percent between 2001 and 2010 as the number of people they care
    for grew by 52 percent.
    Growing Needs, Diminishing Resources
        In 2008, CDC yet again revised upward its estimate of persons
    living with HIV/AIDS in the United States to 1,106,400 (as of 2006).
    Approximately one-half of those people have yet to access HIV-related
    medical care and there is a projected influx of newly diagnosed
    individuals into care as a result of CDC initiatives to promote routine
    HIV testing. CDC also estimates that in 2006, more than 56,000 people
    were newly infected with HIV. Ryan White Program part A, part B base
    and ADAP, part C, and part F AETCs must receive adequate increases to
    meet the healthcare and supportive services needs of individuals
    already in care and those newly identified HIV patients entering care-
    many of whom will require comprehensive medical treatment and
    supportive services at the time of diagnosis.
        Additional increases are desperately needed to address the growing
    demand for services, offset the rising cost of care, and help the many
    jurisdictions forced year after year to make service reductions and
    eliminations to rebuild their programs.
        State budget cuts have created an immediate ADAP funding crisis.
    Many State ADAPs are on the brink of the worst funding shortfall in
    many years and there is a record number of people in need of ADAP
    services due to the economic downturn. As of March 2010, there are 662
    people on ADAP waiting lists in 10 States. Additionally, ADAP waiting
    lists and other cost-containment measures, including limited
    formularies, reducing eligibility, or removing already enrolled people
    from the program, are clear evidence that the need for HIV-related
    medications continues to outstrip availability. ADAPs are forced to
    make difficult trade-offs between serving a greater number of people
    living with HIV/AIDS with fewer services or serving fewer people with
    more services. Additional resources are needed to reduce and prevent
    further use of cost-containment measures to limit access to ADAPs and
    to allow all State ADAPs to provide a full range of HIV antiretrovirals
    and treatment for opportunistic infections.
        The number of clients entering the 357 part C community health
    centers and outpatient clinics has consistently increased over the last
    5 years. More than 248,000 persons living with HIV and AIDS receive
    medical care in part C-funded community health centers and clinics each
    year. These community- and faith-based HIV/AIDS providers are
    staggering under the burden of treatment and care after years of
    funding cuts prior to the modest increase in recent years. The CDC has
    implemented a number of initiatives designed to promote routine HIV
    testing to identify people living with HIV. Their success continues to
    generate new clients seeking care at part C-funded health centers and
    clinics with no commensurate increase in the funds necessary to provide
    access to comprehensive, compassionate treatment and care.
    Increasing Testing Requires Increasing Access to Care
        The fiscal year 2011 appropriation presents a crucial initial
    opportunity to restore the Ryan White Program to the levels of funding
    demanded by the epidemic as the Centers for Disease Control and
    Prevention (CDC) continue their increased efforts to expand HIV testing
    to help people living with HIV learn their status. With the continued
    influx of newly diagnosed individuals into care and the additional
    56,000 estimated new cases of HIV every year, the Ryan White program
    must receive adequate increases to meet the healthcare and supportive
    services needs of individuals already in care and those newly
    identified HIV patients.
        CAEAR Coalition supports efforts to help identify those individuals
    infected with HIV but unaware of their status. However, CAEAR Coalition
    is concerned that without the simultaneous allocation of additional
    resources for treatment, these CDC initiatives have resulted in a
    significant increase in the demand for HIV/AIDS services without the
    capacity in place to provide that care.
        Increased demand for services has placed a severe strain on the
    HIV/AIDS safety net and forced community-based providers to stretch
    already scarce resources even further to address growing needs. This
    additional pressure on an already overburdened system will leave many
    of the 200,000+ HIV-infected individuals who do not know their HIV
    status without access to the care they need. CAEAR Coalition urges
    Congress and the administration to provide a commensurate increase for
    treatment programs to meet the demand that has resulted from the CDC
    testing initiative.
    Sufficient Funding for Ryan White Programs Saves Money and Saves Lives
        Increased funding for Ryan White Programs will reap a significant
    health return for minimal investment. Data show that part A and part C
    programs have reduced HIV-related hospital admissions by 30 percent
    nationally and by up to 75 percent in some locations. The programs
    supported by the Ryan White HIV/AIDS Program also have been critical in
    reducing AIDS mortality by 70 percent. Taken together, the Ryan White
    Program works--resulting in both economic and social savings by helping
    keep people healthy and productive.
        CAEAR Coalition is eager to work with Congress to meet the
    challenges posed by the HIV/AIDS epidemic. Congress and the
    Administration must do more to address the grim reality that the
    domestic epidemic is not static; it is continuing to grow at a
    significant rate and more Federal resources are needed to prevent it
    from becoming a public health catastrophe similar to what we are
    witnessing in the developing world. Already, some communities in the
    United States have infection and death rates similar to those in
    Africa. We must make a commensurate domestic investment to care for
    people in our own communities. CAEAR Coalition looks forward to working
    with the subcommittee and the Congress to help meet the needs of
    Americans living with HIV/AIDS as the appropriations process moves
    forward.
        Given the Ryan White Program's stellar history of accomplishments,
    the vast need for more resources to address unmet need, and such strong
    praise from the Federal Government's most stringent and assiduous
    assessors, we hope the subcommittee will act to provide these
    relatively modest funding increases.
                                     ______

         Prepared Statement of the Council of Academic Family Medicine

        On behalf of the Council of Academic Family Medicine (CAFM), we are
    pleased to submit testimony on behalf of several programs under the
    jurisdiction of the Health Resources and Services Administration (HRSA)
    and the Agency for Healthcare Research and Quality (AHRQ).
        We are very pleased to have supported the Patient Protection and
    Affordable Care Act (PPACA) and to see it enacted into law. We
    appreciate Congress's efforts to extend healthcare coverage to all and
    are pleased that the law contains significant efforts to support and
    sustain programs that will help produce a workforce needed to take care
    of the Nation. As the law acknowledges, there is much that must be done
    to support primary care production and nourish the development of a
    high-quality, highly effective primary care workforce to serve as a
    foundation for our healthcare system.
    Health Care Reform Requires a Robust Primary Care Workforce
        The PPACA contains many measures to address the need for more
    primary care physicians. As you know, 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. The implementation of the 2006 Massachusetts
    healthcare reform law demonstrated that universal coverage will
    overwhelm a healthcare system with too few primary care physicians,
    especially, family physicians. Addressing the shortage of primary care
    physicians requires a long-term commitment to train an appropriate
    number of these essential healthcare providers. We must increase our
    investment in effective programs that encourage medical students to
    enter primary care specialties.
        Toward that end, there are several programs and agencies whose
    domain is critically important to producing more primary care
    physicians and providing them with the tools to support high quality
    care. It is those programs and agencies that come under this
    subcommittee's jurisdiction and that this testimony addresses.
    Primary Care Training and Enhancement
        Section 747 of the Public Health Service Act has a long history of
    providing necessary funding for the training of primary care
    physicians. In each reauthorization Congress has modified the program
    to obtain certain key goals. The current authorization gives direction
    to HRSA to recognize and prioritize training that will support
    development of expertise in new competencies, including those relevant
    to providing care through patient-centered medical homes, development
    of infrastructure within primary care departments for the improvement
    of clinical care and research critical to primary care delivery, as
    well as innovations in team management of chronic disease, integrated
    models of care, and transitioning between healthcare settings. One new
    area of endeavor is the integration of academic administrative units
    within a school of medicine to promote team based care and true primary
    care production. This provision has a separate, additional
    authorization of $750,000.
        The Advisory Committee on Training in Primary Care Medicine and
    Dentistry recommends $235 million for these programs (including
    dentistry which has subsequently been dropped from this cluster). Other
    key advisory bodies such as the Institute of Medicine (IOM) and the
    Congressional Research Service (CRS) call for increased funding. The
    IOM (December 2008) pointed to the drastic decline in title VII funding
    and described these health professions workforce training programs as
    ``an undervalued asset.'' The Congressional Research Service found that
    reduced funding to the primary care cluster has had a negative impact
    on the effectiveness of the programs during a time when more primary
    care is needed (February 2008).
        According to the Robert Graham Center, (Title VII's decline:
    Shrinking investment in the primary care training pipeline, October
    2009), ``the number of graduating U.S. allopathic medical students
    choosing primary care declined steadily over the past decade, and the
    proportion of minorities within this workforce remains low.''
    Unfortunately, this decline coincides with a decline in funding of
    primary care training funding--funding that we know is associated with
    increased primary care physician production and practice in underserved
    areas.

        The report goes on to say that ``the nation needs renewed or
    enhanced investment in programs like Title VII that support the
    production of primary care physicians and their placement in
    underserved areas.'' This situation is only exacerbated by the
    wonderful explosion of people who will gain insurance coverage under
    the new healthcare reform law. Given the tremendous need, we urge the
    Committee to provide a fiscal year 2011 appropriation of $170 million
    for the title VII, section 747 Primary Care Training and Enhancement,
    including the Integrative Academic Administrative Units program, as
    authorized by the Patient Protection and Affordable Care Act. We also
    recommend an appropriation of at least $600 million for all of the
    Health Professions Training Programs authorized under title VII of the
    Public Health Services Act.
    Rural Physician Training Grants
        We were pleased that the PPACA included a new program as part of
    title VII of the Public Health Service Act, section 749B, entitled the
    ``Rural Physician Training Grants'' program. It is intended to increase
    the supply of rural physicians by authorizing grants to medical schools
    which establish or expand rural training. The program would provide
    grants to produce rural physicians of all specialties. It would help
    medical schools recruit students most likely to practice medicine in
    underserved rural communities, provide rural-focused training and
    experience, and increase the number of medical graduates who practice
    in underserved rural communities.
        According to a July 2007 report of the Robert Graham Center
    (Medical school expansion: An immediate opportunity to meet rural
    healthcare needs), data show that although 21 percent of the U.S.
    population lives in rural areas, only 10 percent of physicians practice
    there. The Graham Center study describes the educational pipeline to
    rural medical practice as ``long and complex.'' There are multiple
    tactics needed to reverse this situation, and this grant program
    includes several of them. Strategies to increase the number of
    physicians practicing in rural areas include ``increasing the number of
    rural-background students in medical school, selecting the ``right''
    students and giving them the ``right'' content and experiences to train
    them for rural practice.'' This is exactly what this grant program is
    designed to do.
        We request the subcommittee provide the fully authorized amount of
    $4 million in fiscal year 2011 for title VII, section 749B Rural
    Physician Training Grants.
    Teaching Health Centers Development Grants
        One of the more creative programs to come out of the healthcare
    reform bill as it relates to workforce is the establishment of Teaching
    Health Centers (THCs). These are community health centers or other
    similar venues that sponsor residency programs and provide residents
    with their ambulatory training experiences in the health center. This
    training in the community, rather than solely at the hospital bedside
    is one of the hallmarks of family medicine training. In fact, numerous
    family medicine residency programs currently align with health centers
    to provide residents with their ambulatory continuity training in these
    settings. However, payment issues have always caused a tension and
    struggle between the hospital, which currently receives reimbursement
    for residents it sponsors when they train in the hospital, and programs
    that require training in nonhospital settings. This program is designed
    to provide residency programs and community health centers grant
    funding to plan for a transition in sponsorship, or the establishment
    of new programs.
        It allows the Secretary to award grants to THCs (community based
    ambulatory patient care centers that operate a primary care residency
    program; listed as FQHC, rural health clinic, community mental health
    center, health center operated by Indian Health Service, or a center
    receiving title X grants) to establish new accredited or expanded
    primary care residency programs. We were pleased that the Patient
    Protection and Affordable Care Act authorized a mandatory
    appropriations trust fund of $230 million over 5 years to fund the
    operations of Teaching Health Centers. However, if this program is to
    be effective, there must be funds for the planning grants to establish
    newly accredited or expanded primary care residency programs.
        We recommend the subcommittee appropriate the full authorized
    amount for the new title VII Teaching Health Centers development grants
    of $50 million for fiscal year 2011.
    AHRQ
        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. 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.
        The Institute of Medicine'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.
        We support the President's budget request for AHRQ in fiscal year
    2011 of $611 million. With the inclusion of new programs authorized
    under the PPACA, we support a total appropriations level of $731
    million for the Agency.
    Primary Care Extension Program
        One of the most exciting new programs to be included in the new
    healthcare reform law is one that utilizes the experience of the United
    States Agriculture Extension Service as its model. This new program,
    under title III of the Public Health Service Act, is designed to
    support and assist primary care providers with the adoption and
    incorporation of techniques to improve community health. As the authors
    of an article describing this new concept (JAMA, June 24, 2009) have
    stated, ``To successfully redesign practices requires knowledge
    transfer, performance feedback, facilitation, and HIT support provided
    by individuals with whom practices have established relationships over
    time. The farming community learned these principles a century ago.
    Primary care practices are like small farms of that era, which were
    geographically dispersed, poorly resourced for change, and inefficient
    in adopting new techniques or technology but vital to the Nation's
    well-being.''
        Congress agreed with the authors that ``practicing physicians need
    something similar to the agricultural extension agent who was so
    transformative for farming,'' and authorized this program at $120
    million for fiscal year 2011 and 2012.
        We support the President's budget request for AHRQ in fiscal year
    2011 of $611 million. In addition, since the $611 million does not
    include this newly passed provision, we request the subcommittee
    provide AHRQ with an additional $120 million for the Primary Care
    Extension program authorized by the health reform law, bringing the
    total request to $731 million.
    Workforce Commission
        We have recognized the need, and called for a national commission
    on health workforce issues for many years. We are pleased that the
    PPACA established a National Health Care Workforce Commission to
    provide ``analysis of, and recommendations for, eliminating the
    barriers to entering and staying in primary care, including provider
    compensation.'' We also recognize the importance of the National Center
    for Health Care Workforce Analysis as well as State and Regional
    Centers for such analysis. PPACA authorizes such sums as necessary to
    establish the Commission as well as $8 million in planning grants and
    $150 million for implementation grants. The National Center was
    authorized at $7.5 million annually and the State and Regional Centers
    were authorized at $4.5 million annually.
        We recommend the Committee fully fund the National Health Care
    Workforce Commission, the National and State and Regional Centers for
    Health Care Workforce Analysis in fiscal year 2011.
        We appreciate the work of the Committee in making difficult choices
    when funding many critical programs. We caution the committee not to
    ruin the positive impact of healthcare reform by not supporting the
    complementary programs that are so necessary to its success.
                                     ______

       Prepared Statement of the Coalition for the Advancement of Health
                 Through Behavioral and Social Science Research

        Mr. Chairman and members of the subcommittee, the Coalition for the
    Advancement of Health Through Behavioral and Social Science Research
    (CAHT-BSSR) appreciates and welcomes the opportunity to comment on the
    fiscal year 2011 appropriations for the National Institutes of Health
    (NIH). CAHT-BSSR includes 13 professional organizations, scientific
    societies, coalitions, and research institutions concerned with the
    promotion of and funding for research in the social and behavioral
    sciences. Collectively, we represent more than 120 professional
    associations, scientific societies, universities, and research
    institutions.
        CAHT-BSSR would like to thank the subcommittee and the Congress for
    its continued support of the NIH. Strong sustained funding is essential
    to national priorities of better health and economic revitalization.
    Providing adequate resources in fiscal year 2011 that allows the NIH to
    keep up with the rising costs of biomedical, behavioral, and social
    sciences research will help NIH begin to prepare for the era beyond
    recovery. It is essential that funding in fiscal year 2011 and beyond
    allow the agency to resume steady, sustainable growth and allow for
    fulfilling the President's vision of doubling our investment in basic
    research. Accordingly, CAHT-BSSR joins the Ad Hoc Group for Medical
    Research in its request for $35 billion in funding for NIH in fiscal
    year 2011. This level of funding will sustain America's enhanced
    medical research capacity. It also represents the new functional
    capacity funded by annual appropriations and the historic American
    Recovery and Reinvestment Act (ARRA).
        NIH Behavioral and Social Sciences Research.--NIH supports
    behavioral and social science research throughout most of its 27
    institutes and centers. The behavioral and social sciences regularly
    make important contributions to the well-being of this Nation. Due in
    large part to the behavioral and social science research sponsored by
    the NIH, we are now aware of the enormous contribution behavior makes
    to our health. At a time when genetic control over diseases is
    tantalizingly close but not yet possible, knowledge of the behavioral
    influences on health is a crucial component in the Nation's battles
    against the leading causes of morbidity and mortality: obesity, heart
    disease, cancer, AIDS, diabetes, age-related illnesses, accidents,
    substance use and abuse, and mental illness.
        As a result of the strong congressional commitment to the NIH in
    years past, our knowledge of the social and behavioral factors
    surrounding chronic disease health outcomes is steadily increasing. The
    NIH's behavioral and social science portfolio has emphasized the
    development of effective and sustainable interventions and prevention
    programs targeting those very illnesses that are the greatest threats
    to our health, but the work is just beginning.
        The grandest challenge we face is understanding the brain,
    behavior, and society--from global warming to responding to short term
    pleasures; from self destructive behavior, such as addiction, to life
    style factors that determine the quality of life, infant mortality rate
    and longevity. Nearly 125 million Americans are living with one or more
    chronic conditions, like heart disease, cancer, diabetes, kidney
    disease, arthritis, asthma, mental illness and Alzheimer's disease.
    Significant factors driving the increase in healthcare spending in the
    United States are the aging of the U.S. population, and the rapid rise
    in chronic diseases, many caused or exacerbated by behavioral factors:
    for example, obesity, caused by sedentary behavior and poor diet;
    addictions and resulting health problems caused by tobacco and other
    drug use. Behavioral and social sciences research supported by NIH is
    increasing our knowledge about the factors that underlie positive and
    harmful behaviors, and the context in which those behaviors occur.
        CAHT-BSSR applauds the NIH's recognition that the ``scientific
    challenges in developing an integrated science of behavior change are
    daunting.'' We especially commend the new basic behavioral and social
    science research trans-NIH initiative, Opportunity Network for Basic
    Behavioral and Social Sciences Research (OppNet), being undertaken by
    the NIH to examine the important scientific opportunities that cut
    across the structure of NIH and designed to look for strategic
    opportunities to build areas of research where there are gaps and that
    have the potential to affect the missions of multiple institutes and
    centers. Research results could lead to new approaches for reducing
    risky behaviors and improving health.
        Likewise, we commend the designation of the ``Science of Behavior
    Change'' Roadmap Initiative included in the third cohort of research
    areas for the Common Fund. We agree with the goals of this Roadmap
    Pilot to ``establish the groundwork for a unified science of behavior
    change that capitalizes on both the emerging basic science and the
    progress already made in the design of behavioral interventions in
    specific disease areas. By focusing basic research on the initiation,
    personalization, and maintenance of behavior change, and by integrating
    work across disciplines, this Roadmap effort and subsequent trans-NIH
    activity could lead to an improved understanding of the underlying
    principles of behavior change. This should drive a transformative
    increase in the efficacy, effectiveness, and (cost) efficiency of many
    behavioral interventions.''
        With the recent passage of healthcare reform legislation, there has
    been the accompanying and appropriate attention to the issue of
    personalized healthcare. CAHT-BSSR believes that personalization needs
    to reflect genes, behaviors, and environments. And as the agency has
    acknowledged with its recent support of the Science of Behavior Change
    initiative, assessing behavior is critical to helping individuals see
    how they can improve their health. It is also critical to helping
    healthcare systems see where it needs to put resources for behavior
    change. Fortunately, the NIH acknowledges the need to focus less on
    finding the ``magic answer'' and, at the same time, recognizes that
    healthcare is different from region to region across the country. Full
    personalization needs to consider the environmental, community, and
    neighborhood circumstances that govern how individuals' genes and
    behavior will influence their health. For personalized healthcare to be
    realized, we need a sophisticated understanding of the interplay
    between genetics and the environment, broadly defined.
        CAHT-BSSR applauds the NIH's recognition of a unique and compelling
    need to promote diversity in health-related research. The agency
    expects these efforts to lead to: the recruitment of the most talented
    researchers from all groups; an improvement in the quality of the
    educational and training environment; a balanced perspective in the
    determination of research priorities; an improved ability to recruit
    subjects from diverse backgrounds into clinical research; and an
    improved capacity to address and eliminate health disparities. Numerous
    studies provide evidence that the biomedical and educational enterprise
    will directly benefit from broader inclusion.
        NIH recognizes that developing a more diverse and academically
    prepared workforce of individuals in S.T.E.M. disciplines will benefit
    all aspects of scientific and medical research and care. CAHT-BSSR
    applauds the agency its recognition that to remain competitive in the
    21st century global economy, the Nation must foster new opportunities,
    approaches, and technologies in math and science education. This
    recognition extends to the need for a coordinated effort to bolster
    science, technology, engineering, and math (S.T.E.M.) education
    nationwide, starting at the earliest stages in education. We applaud
    the agency for its use of ARRA funds to support research designed to
    strengthen and enhance efforts to attract young people to biomedical
    and behavioral science careers and to improve science literacy in
    adults and children.
        CAHT-BSSR also commends the NIH for commissioning the Institute of
    Medicine (IOM) study of LGBT (lesbian, gay, bisexual, and transgender)
    health issues, research gaps and opportunities. LGBT populations are
    among those for whom little or no national-level health data exist
    resulting in significant gaps in knowledge and research on LGBT health.
    At the same time, multidisciplinary research has begun to identify
    important sexual orientation and gender identity-related health
    concerns and disparities. The IOM study is a step in the right
    direction to begin to address many of the research challenges this
    issue presents, including methodological limitations. The study could
    examine the best methodological practices for investigating health
    concerns in LGBT communities. It also provides the opportunity for the
    development of a strategic plan for the NIH to investigate and address
    the health concerns of LGBT people. At the very least, the IOM study
    could examine the current state of knowledge on LGBT health, including
    general health concerns and health disparities.

             NIH OFFICE OF BEHAVIORAL AND SOCIAL SCIENCES RESEARCH

        The NIH Office of Behavioral and Social Sciences Research (OBSSR),
    authorized by Congress in the NIH Revitalization Act of 1993 and
    established in 1995, serves as a convening and coordinating role among
    the institutes and centers at NIH. In this capacity, OBSSR develops,
    coordinates, and facilitates social and behavioral science research
    agenda at NIH; advises the NIH director and directors of the 27
    Institutes and Centers; informs NIH and the scientific and lay publics
    of social and behavioral science research findings and methods; and
    trains scientists in the social and behavioral sciences. For fiscal
    year 2011, CAHT-BSSR supports a budget of $41.32 million for OBSSR
    commensurate with the administration's request of $38.2 million for the
    Office and the scientific community's request for the NIH as a whole.
        To achieve its vision of bringing together the biomedical,
    behavioral, and social sciences research communities to work towards
    solving the most pressing health challenges faced by society, OBSSR is
    expanding its efforts to promote and support social and behavioral
    science research in four areas: (1) problem-based research; (2) basic
    science; (3) systems-thinking approaches to population health; and (4)
    interdisciplinary team science. Given the NIH's focus on gene and
    environment interaction, new leading edge research examining how social
    and behavioral factors change or alter the actions of genes to
    influence health and disease is needed.
        OBSSR focuses on cross-cutting behavioral and social research
    issues (e.g., ``Long-term Maintenance of Behavior Change'') using its
    modest budget to seed cross-institute research initiatives. OBSSR has
    spurred cutting edge research in areas such as measures of community
    health, including new community-based participatory programs supporting
    intervention research methods to disease prevention and health
    promotion in medically underserved areas; socioeconomic status; health
    literacy; and new methodology development.
        In fiscal year 2011, OBSSR, in addition to continuing to support
    cross-cutting behavioral and social science research issues intends to
    address the issue of health literacy. Low health literacy is a wide
    spread problem, affecting more than 90 million adults in the United
    States, where 43 percent of adults demonstrate only the most basic or
    below-basic levels of prose literacy. Low health literacy results in
    patients' inadequate engagement in decisions regarding their healthcare
    and can hinder their ability to realize the benefits of healthcare
    advances. Research has linked low or limited health literacy with such
    adverse outcomes as poorer self-management of chronic diseases, fewer
    healthy behaviors, higher rates of hospitalizations, and overall poorer
    health outcomes. These situations hamper the effectiveness of health
    professionals' efforts to prevent, diagnose and treat medical
    conditions, and limit many healthcare consumers' abilities to make
    important healthcare decisions.
        CAHT-BSSR would be pleased to provide any additional information on
    these issues. Below is a list of coalition member societies. Again, we
    thank the subcommittee for its generous support of the National
    Institutes of Health and for the opportunity to present our views.
        CAHT-BSSR
        American Educational Research Association
        American Psychological Association
        American Sociological Association
        Association of Population Centers
        Center for the Advancement of Health
        Consortium of Social Science Associations
        Council on Social Work Education
        Federation of Associations in Behavioral & Brain Sciences
        National Association of Social Workers
        Population Association of America
        Society for Behavioral Medicine
        Society for Research in Child Development
        The Alan Guttmacher Institute (AGI)
                                     ______

       Prepared Statement of the Center for American Progress Action Fund

        The Center for American Progress Action Fund commends the Senate
    Appropriations Committee and the House Labor, Health and Human
    Services, Education Appropriations Subcommittee for reporting out
    strong fiscal year 2011 Labor, Health and Human Services, Education
    Appropriations bills. Both pieces of legislation make investments in
    the innovative education reform programs needed to make our schools
    better.
        These education reform programs, proposed by the Obama
    administration and funded through the two Labor-HHS bills, constitute
    the right mix of formula-based funding and innovation promotion
    necessary to improve our schools. Some may question the soundness of
    investing in innovative reforms at a period when our country is still
    working to recover from the recession. The reality, however, is that
    the need for innovation has never been greater. School achievement has
    remained essentially flat for more than 30 years, and without
    significant changes in the way we fund and operate schools we will
    almost certainly not see any significant gains in the future.
        We wanted to share our recommendations for the educational
    priorities outlined below as the House and Senate prepare to reconcile
    the two bills before final passage in either a standalone bill or
    within an omnibus spending bill.
    Race to the Top
        Race to the Top, a competitive grant program, has been a part of
    the Federal education agenda for only a short period. But it has
    already yielded some of the most significant reforms ever seen in
    education by tying Federal dollars to systemic education reform.
    Twenty-eight States changed their policies in 2009 and 2010 to improve
    their chances of winning a piece of the pie. We urge you to include the
    House funding level of $800 million, which will allow us to continue
    building on these early successes.
        Race to the Top was originally enacted through the American
    Recovery and Reinvestment Act, or ARRA, and has not been authorized.
    CAP Action urges the committee to use its authority to fund this
    promising program.
    Investing in Innovation Fund
        The House bill includes $400 million for the Investing in
    Innovation, or i3 fund, which is nearly the full amount of the
    President's request. This program was also enacted through ARRA and has
    not been authorized. But we again urge you to use your authority to
    include this funding level in the final bill. The i3 fund awards grants
    to districts as well as nonprofit organizations partnering with schools
    and districts to scale up evidence-based practices and programs.
        There already has been promising growth in nonprofit educational
    entrepreneurs such as the New Teacher Project and College Summit, but
    these have been established in the absence of significant Federal
    investment. They rely instead on philanthropy, the private sector, and
    local school district contracts. While their achievements have been
    dramatic, limited funding and other policy barriers challenge efforts
    to take their practices to scale.
    Teacher Incentive Fund
        The Teacher Incentive Fund is a 4-year-old appropriations line item
    that supports competitive grants to States and school districts to
    implement pay-for-performance programs in high-needs schools. TIF funds
    may also support pay for teaching in subject shortage areas such as
    mathematics and science as well as career ladders for teachers that
    offer them additional pay for increased responsibilities.
        Critics argue that ``merit pay'' is a failed policy that has been
    around since the early 1900s. But the truth is that past merit pay
    programs were destined to fail. They were based on subjective measures
    of teacher performance and weren't part of a comprehensive plan to
    improve teachers' instructional practice. The kinds of programs TIF now
    supports are generally comprehensive programs that include professional
    development, high-quality evaluation, and performance-based
    compensation. And the Department of Education's new guidance for TIF
    has an even greater focus on comprehensive approaches.
    Title I School Improvement Grants
        Our education system desperately needs resources to turn around the
    Nation's lowest-performing schools. School improvement grants support
    targeted reforms at the lowest-achieving 5 percent of Title I schools
    in each State. The SIG program also funds efforts to decrease the
    number of ``drop-out'' factories, or high schools that continually
    graduate 60 percent or less of students.
        Through the use of SIG funds we are finally seeing the type of
    dramatic interventions needed to end the cycle of underperformance at
    these schools. We are also encouraged by the recommendation made by the
    Senate Appropriations Committee Report (111-243) that SIG funds be used
    to support strategies meeting more rigorous evidentiary standards (see
    discussion below).
        Unfortunately, too few dollars reach the schools with the greatest
    need, particularly high schools. While the funding level in the House
    bill remains embargoed, CAP Action urges the committee to move forward
    with the Senate funding level of $625 million in school improvement
    grants and help ensure that a more significant proportion of these
    dollars reach middle and high schools.
    21st Century Learning Centers Program
        The Senate Labor-HHS bill includes $1.266 billion--a $100 million
    increase--in funding for the 21st Century Community Learning Centers
    program, or CCLC, which has traditionally funded afterschool programs,
    to support expanded learning time and community schools. CAP Action
    urges you to include this level of funding in the final legislation as
    well as the report language that provides new flexibility to use funds
    to expand school time.
        Expanded learning time schools formally incorporate traditional
    out-of-school activities-including enrichment activities such as the
    arts and service opportunities-into the official school calendar so
    that all students have access, including those living in high poverty.
    Expanded learning time can close not only academic achievement gaps but
    enrichment gaps as well.
        Community schools are fully equipped to tackle ``out-of-school''
    barriers by opening up social and health resources to students and
    their families. Community schools that seamlessly integrate academic
    and nonacademic services help educators navigate the effects of
    poverty, ill health, and language barriers so students are ready to
    learn every day.
        CCLC dollars are currently limited to activities during nonschool
    hours, which prohibits the expansion of expanded learning time and
    community schools. CAP Action thus calls on the committee to lift this
    prohibition and provide States, districts, and schools with the
    flexibility to choose to dedicate these dollars to the models that best
    suit their students' needs.
    Charter Schools Program
        The Charter Schools Program provides grants to States to support
    the planning and development of new charter schools. This funding is
    critical because charter schools usually receive less public funding
    than traditional public schools. In fact, a recent study finds that
    charter schools receive 19.2 percent less funding per pupil on average.
        The existence of charter schools has spurred the development of
    some of the most promising school models for educating disadvantaged
    students. School models like KIPP, Yes Prep, and Achievement First have
    achieved unprecedented outcomes for students in poverty and have even
    outperformed schools with higher-income students. A recent Mathematica
    study of KIPP middle schools found that the schools had a positive
    impact on students' math and reading achievement 4 years after students
    entered the schools.
        High-achieving charter schools like these would not exist without
    adequate financial support. We understand that the House bill includes
    $266 million in funding for the Charter School Program, and we urge you
    to include this in the final legislation.
    Promise Neighborhoods
        Promise Neighborhoods are focused on improving educational outcomes
    for children living in our most distressed communities and represent an
    unprecedented shift in how localities address child poverty and
    academic opportunity. Each Promise Neighborhood will provide ``cradle-
    to-career'' services to support students who attend schools in a
    designated geographic area. Schools, city governments, colleges and
    universities, nonprofits, health providers, and other organizations in
    each Promise Neighborhood will collaborate to finally break down the
    silos that may have prevented past efforts to help low-income students
    achieve.
        The Department of Education recently awarded 21 planning grants to
    communities across the country to create Promise Neighborhoods. The
    important work funded by these planning grants will be wasted without
    sufficient funding in the fiscal year 2011 budget to scale up these
    initiatives. We hope you will provide at least $60 million for Promise
    Neighborhoods--as was included in the House bill--and encourage you to
    provide more if possible to bring the funding level closer to the
    Administration's original request of $210 million.
    Evidence-based intervention
        The Senate Appropriations Committee Report (111-243) calls for a
    refinement of the criteria relating to interventions appropriate for
    persistently failing schools. We strongly support this language, which
    encourages the Department of Education to urge States and districts to
    use their Title I School Improvement Grants only for interventions that
    meet two standards of evidence specified by the Investing in Innovation
    (i3) grant program. Specifically, Congress should stipulate that the
    Department of Education foster the use of intervention strategies
    meeting the evidence standards required of ``validation'' grants or
    ``scale-up'' grants under i3.
        This approach honors the idea that educators should strive
    generally to expose children to research-based practices. And it
    creates a logical connection between the department's support for
    research and development on the one hand and its support for sound
    practice on the other.
        A challenging economy requires responsible Federal spending. CAP
    Action believes the fiscal year 2011 education appropriations budget
    should target investment to support the necessary innovative reforms to
    strengthen our schools for the 21st century. The House LHHS
    subcommittee and the Senate Appropriations Committee both produced
    strong bills. Together they will help to provide all of America's young
    people with a high-quality education that prepares them for college and
    a career. Thank you for your consideration.
                                     ______

              Prepared Statement of the Center for Civic Education

        I appreciate the opportunity to present this testimony requesting
    continued support of $35 million (the same amount as fiscal year 2010)
    for the civic education program (Elementary and Secondary Education
    Act, Sections 2341-2346) that the U.S. Department of Education (ED) cut
    from its fiscal year 2011 budget request to Congress. I am Charles N.
    Quigley, executive director of the Center for Civic Education (Center),
    the principal organization supported under the Education for Democracy
    Act.
        Other worthy organizations supported under the Act include the
    Center on Congress at Indiana University (COC), the National Conference
    of State Legislatures (NCSL), the Council for Economic Education, and a
    domestic network of public- and private-sector organizations in every
    State and Congressional District in the Nation. Together with the
    Center, these organizations provide effective programs in civic and
    economic education to millions of students annually at precollegiate
    levels in the United States and in more than 80 emerging and advanced
    democracies throughout the world.
        The justification for the elimination of funding for the civic
    education program, namely, that such activities would be continued
    through a consolidated competitive program of relatively small grants,
    is not supported by the facts. Furthermore, it overlooks the valuable
    national infrastructure of programming--supported by Congress through
    many years of directed funding--that would be lost without this
    sustained investment. The national program funded under the Education
    for Democracy Act is implemented with the assistance of an extensive
    network of State and congressional district coordinators that provides
    equal support to schools in every congressional district in the form of
    free curricular materials, assistance in professional development, and
    other technical assistance. This equal support for schools in each
    congressional district would not be available under the proposed
    consolidation plan.

                        THE EDUCATION FOR DEMOCRACY ACT

        The Education for Democracy Act (EDA) supports highly successful
    national and international projects authorized and approved by the U.S.
    Congress and funded by the U.S. Department of Education. Since 1987,
    directed funding from the EDA has ensured that more than 30 million
    students across the Nation have been taught the principles of American
    constitutional democracy through the We the People: The Citizen and the
    Constitution program and related programs. In addition, millions of
    students in emerging democracies throughout the world have benefited
    from the civic and economic education exchange programs supported by
    the EDA. The proposed elimination of this directed funding in favor of
    competitive grants to numerous smaller initiatives would ensure the
    destruction of this proven, exemplary domestic civic education program
    representing 22 years of federally funded investment.
        Congress has long recognized that directed funding is essential for
    certain large-scale projects of national significance. The improvement
    of civic education in the United States and the establishment of
    effective civic and economic education programs in emerging democracies
    require a large-scale, long-term program involving the establishment of
    extensive national implementation networks supported by highly skilled,
    experienced, and dedicated staff. It would be grossly inefficient and
    extremely difficult to achieve the goals of such programs through a
    number of relatively small and uncoordinated grants with 2- to 5-year
    timelines.
        The civic education programs (We the People and related programs),
    authorized by the EDA, are: cost effective; validated by independent
    research; effective in raising student academic achievement in schools
    throughout the country; implemented nationwide in every congressional
    district; administered locally by dedicated volunteers; supported by
    professional development for teachers; providers of free, high-quality
    curricular materials for students and teachers; and supported by
    Congress and numerous national, State, and local public- and private-
    sector groups.
        Furthermore, the Cooperative Education Exchange Program's
    international civics programs promote U.S. foreign policy objectives in
    more than 80 countries, encourage respect for human rights, and promote
    commitment to democratic values and principles in emerging democracies.

                       BENEFITS OF THE DOMESTIC PROGRAMS

        Cost-effective civic education in every congressional district.
    Over 22 years, the EDA has ensured the civic education of more than 30
    million students nationwide. On average, in each congressional district
    the existing program annually supports a total of 5,700 students; in
    190 classes at the elementary, middle, and high school levels; and at a
    cost of $7.20 per student--far less than the retail cost of one history
    or civics textbook.
        Note: The program currently reaches approximately 2.5 million
    students each year. It is highly unlikely that a competitive,
    relatively small grant program would reach as many students in every
    congressional district of the Nation as cost effectively as the We the
    People Programs.
        Proven Impact on Student Outcomes.--The We the People Programs are
    independently proven to be effective. Evaluations by the Educational
    Testing Service, Stanford University, RMC Research Corporation, and
    others have shown that the We the People Programs have had a
    statistically significant positive effect on student knowledge, skills,
    dispositions, and behaviors (see www.civiced.org/research).
        Note: To place the funding for these programs in a competitive
    grant program would be to discard proven programs developed and
    implemented with Federal dollars in favor of numerous smaller programs
    that lack any independent evidence of proven effectiveness.
        National Network.--The We the People Programs have grassroots
    community support in every congressional district. They are implemented
    by a national civic education network of 120 public- and private-sector
    organizations in all 50 States and the District of Columbia and 123
    representatives of local education agencies or civic-minded community
    groups at the congressional district level.
        Note: In every State, the We the People Programs are supported by
    an extensive network of civic educators and community volunteers who
    administer the programs and raise funds to support local program
    activities. This network would cease to exist if its funding were to be
    placed in a competitive grant program.
        Effective Use of Federal Dollars.--Approximately 70 percent of the
    funding for the program is distributed equitably to every congressional
    district. The funds provide free curricular materials for elementary,
    middle, and high schools; professional-development programs for
    teachers; and funding at the State and congressional district levels
    for the implementation of curricular programs in civic education.
        Note: A competitive program of relatively small grants would not
    result in such an effective and equitable distribution of resources.
    Instead, many congressional districts would receive little or no
    assistance in implementing civic education programs.
        In addition, funding relatively large nationwide programs--such as
    the We the People Programs--compared to funding numerous smaller
    programs is more likely to be cost effective in controlling
    administrative costs and providing more funding for programmatic costs.
    As noted above, approximately 70 percent of the funds the Center
    received for its USED-supported programs were spent for programmatic
    costs throughout the United States. The remaining 30 percent consists
    of staff and benefits (approximately 20 percent) and general
    administrative costs (approximately 10 percent). Of the staff costs,
    some are for general administration, but a considerable amount is for
    technical assistance to State and local programs for such purposes as
    professional development and evaluation.
        Curriculum Backed by Professional Development of Teachers.--The
    Center sponsors professional development activities throughout the
    Nation with the assistance of a national network of directors, mentor
    teachers, and scholars. These activities range in length from less than
    1 day to 7 days. Participants explore content, teaching methods, and
    assessment strategies. Free materials are provided for participants.
        Innovative Content and Methods.--The We the People program is the
    first curriculum based entirely on constitutional principles and
    history. Students take part in a competition on constitutional topics
    that takes the form of simulated congressional hearings. This is an
    educational innovation that works. There is no other civic education
    competition in the world comparable to the We the People program.
        Note: Elimination of directed EDA funding for We the People would
    mean the elimination of district, State, and national simulated
    congressional hearings, during which students compete in a test of
    knowledge and understanding of contemporary and historical issues
    surrounding the Constitution. These hearings have inspired students to
    choose lives of active citizenship, public service, and civic
    engagement.
        Adherence to Authorizing Language.--Congress recognized the
    national need for programs that develop a reasoned commitment to
    American constitutional democracy and the ability of young people to
    participate competently and responsibly in the political life of the
    Nation. The programs supported under the EDA have demonstrated their
    efficacy in promoting such goals.
        Note: To eliminate support for these proven, effective programs and
    place their funding into a competitive grant program would be to
    withdraw the long-term investment of the Federal Government in programs
    proven to yield high returns. Federal funding would instead be spent on
    unproven programs with unpredictable outcomes.

                     BENEFITS OF THE INTERNATIONAL PROGRAMS

        Promoting U.S. Foreign Policy Objectives Abroad.--The Cooperative
    Education Exchange Program's civics and economics programs help to
    institutionalize democratic ideals in more than 80 emerging and
    established democracies worldwide. These highly successful programs,
    helping to meet the U.S. foreign policy objectives of promoting
    democracy, human rights, and an understanding of the principles of
    market economies and their relationship to democracy are not mentioned
    in the ED alternative, thereby ignoring the intent of Congress to
    support these critical programs.
        International Network for Democracy Promotion.--The Civitas
    International Exchange Program created a network of international
    public- and private-sector organizations and colleagues and their
    American counterparts in 30 States. The members of this network work in
    unison to translate and adapt civics textbooks to help educational
    systems in emerging democracies teach democratic principles and values.
    Without the support of the EDA, the network would be eliminated and
    highly effective programs in these emerging democracies would be
    deprived of the support needed for their institutionalization. It is
    estimated that these programs reach 1.5 million students each year at a
    cost of $3 per student.

                                   CONCLUSION

        The Education for Democracy Act programs have been highly
    scrutinized by Congress since their inception in 1987 and have
    undergone multiple authorizations in the law and annual approval in the
    appropriations process. They have survived multiple sessions of
    Congress and several administrations, including initiatives to downsize
    and reinvent Government. Recent ``Dear Colleague'' letters in support
    of the EDA routinely received the support of more than 100 members of
    the House and nearly half of the Senate. There are compelling reasons
    for this support that ultimately reflect a simple truth--the programs
    have a proven track record of success in furthering support for
    democracy; fostering competent and responsible participation by
    students in the political life of their communities, States, and
    nations; raising student academic achievement; improving teacher
    quality; and providing schools with free, exemplary curricular programs
    and technical assistance.

            SUPPORT FOR A COMPETITIVE CIVIC EDUCATION GRANT PROGRAM

        The Center supports the establishment in ED of a competitive grant
    program in civics and government in addition to continued support for
    the current programs. There are many other public- and private-sector
    agencies working in the field of civic education worthy of support. A
    large percentage of these groups are colleagues and participants in the
    Center's domestic networks. A new, competitive grant program could
    result in the development and promulgation of new ideas and programs to
    enhance the field. Such support from both the public and private
    sectors, in fact, gave the Center its start in 1965. The Center is
    working with representatives of other organizations in the field to
    support the inclusion of a competitive grant program in the
    reauthorization of the Elementary and Secondary Education Act.
                                     ______

      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 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.
        Let me express at the outset how appreciative we are for the
    leadership this subcommittee has provided in advancing funding for the
    National Institutes of Health. 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.
        Mr. Chairman, I will focus the remainder of my testimony on our
    appropriations recommendations for fiscal year 2011.

                      RECOMMENDATIONS FOR FISCAL YEAR 2011

    Centers for Disease Control and Prevention
                Inflammatory Bowel Disease Epidemiology Program
        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. Mr. Chairman, we are extremely grateful
    for your leadership in providing funding over the past 5 years for an
    epidemiology program focused on IBD at the Centers for Disease Control
    and Prevention. This program is the only one of its kind in our long
    fight against IBD and its accomplishments have been applauded by the
    CDC. Unfortunately, the President's fiscal year 2011 budget proposal
    recommends that this highly successful program be eliminated. CCFA
    strongly disagrees with the administration's position and urges the
    subcommittee to provide full funding for this important research in
    fiscal year 2011.
        CCFA has been a proud partner with CDC in conducting the research
    funded under the epidemiology program. For the first 2 years of the
    project the Foundation worked collaboratively with Kaiser Permanente in
    California to better understand the incidence and prevalence of IBD,
    the natural history of the disease, and why patients respond
    differently to the same therapy. This research has resulted in 11
    publications to date and another 11 papers to be submitted to high-
    quality peer-reviewed journals. Topics include but are not limited to
    the following:
      --Incidence and Prevalence of IBD;
      --Patterns of Care and Outcomes in IBD;
      --Qualitative study of provider opinions;
      --Utilization of biologics (Infliximab);
      --Disparities in Mortality;
      --Myelosuppression during Thiopurine Therapy for Inflammatory Bowel
            Disease: Implications for Monitoring Recommendations;
      --Severity and Flare Algorithms;
      --Disparities in Surveillance for Colorectal Cancer;
      --Pediatric Epidemiology.
        In 2007, our focus shifted to the establishment of the ``Ocean
    State Crohn's & Colitis Area Registry'' or OSCCAR. Under the leadership
    of Dr. Bruce Sands, this study is being conducted jointly by
    investigators at the Massachusetts General Hospital and Rhode Island
    Hospital/Brown University. The State of Rhode Island is an excellent
    location to conduct a population-based IBD study because (1) it is a
    small state geographically; (2) it has a diverse ethnic and
    socioeconomic population that does not tend to migrate out of State:
    and (3) a small number of gastroenterologists treat essentially all IBD
    patients within the State. Since 2007, Dr. Sands has been able to
    recruit virtually all GI physicians in Rhode Island to refer patients
    into the study. To date, almost 200 patients have been recruited. All
    of this progress will be lost if the program is eliminated in 2011.
        The goals of the OSCCAR study moving forward are to: (1) describe
    the age and sex adjusted incidence rate of Crohn's disease and
    ulcerative colitis; (2) describe variations in presenting symptoms
    among children, men and women with newly diagnosed disease; (3)
    identify factors that predict resistance to steroids, including
    clinical characteristics and blood test markers that could be useful to
    treating physicians; (4) identify predictors of the need for surgery;
    and (5) describe factors that predict either impaired quality of life
    or a benign course of disease.
        Mr. Chairman, to ensure that this important epidemiological work
    moves forward in fiscal year 2011, CCFA recommends an appropriation of
    $686,000 (level funded from fiscal year 2010).

             PEDIATRIC INFLAMMATORY BOWEL DISEASE 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 2011.

                         NATIONAL INSTITUTES OF HEALTH

        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.
        Mr. Chairman, NIDDK-sponsored research on IBD has been a remarkable
    success story. In 2008, a consortium of researchers from the United
    States, Canada, and Europe identified 21 new genes for Crohn's disease.
    This discovery, funded in part by the NIDDK, brings the total number of
    known genes associated with Crohn's disease to more than 30 and
    provides new avenues for the development of promising treatments. We
    are grateful for the leadership of Dr. Stephen James, Director of
    NIDDK's Division of Digestive Diseases and Nutrition, for aggressively
    pursuing this and other promising areas of research.
        CCFA's scientific leaders, with significant involvement from NIDDK,
    have developed an ambitious research agenda entitled ``Challenges in
    Inflammatory Bowel Diseases.'' In addition, CCFA-affiliated
    investigators played a leading role in developing the recommendations
    on IBD in the new NIH National Commission on Digestive Diseases
    strategic plan. We look forward to working with the NIDDK to advance
    the cutting-edge science called for in these two roadmaps.
        Mr. Chairman, I also wanted to thank you and your colleagues for
    the unprecedented support you provided to the NIH as part of the
    American Recovery and Reinvestment Act. IBD research has benefited
    substantially from that investment with more than 15 IBD-specific
    projects receiving ARRA funding. This portfolio includes grants focused
    on; pediatric IBD, clinical diagnostics, basic research on the
    mechanisms of chronic inflammation and the role of the intestinal
    barrier in IBD, genetics, and new therapeutic approaches. This research
    has the potential to dramatically improve the quality of life for our
    patients and we thank you for making this possible.
        For fiscal year 2011, CCFA joins with other voluntary patient and
    medical organizations in recommending an appropriation of $35 billion
    for the NIH. Once again Mr. Chairman, thank you very much for the
    opportunity to submit our views for your consideration.
                                     ______

     Prepared Statement of the Charles R. Drew University of Medicine and
                                    Science

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present you with testimony. The Charles Drew University
    is distinctive in being the only dually designated Historically Black
    Graduate Institution and Hispanic Serving Institution in the Nation. We
    would like to thank you, Mr. Chairman, for the support that this
    subcommittee has given to our University to produce minority health
    professionals to eliminate health disparities as well as do
    groundbreaking research to save lives.
        The Charles Drew University is located in the Watts-Willowbrook
    area of South Los Angeles. Its mission is to prepare predominantly
    minority doctors and other health professionals to care for underserved
    communities with compassion and excellence through education, clinical
    care, outreach, pipeline programs, and advanced research that makes a
    rapid difference in clinical practice. The Charles Drew University has
    established a national reputation for translational research that
    addresses the health disparities and social issues that strike hardest
    and deepest among urban and minority populations.
    Health Resources and Services Administration (HRSA)
        Title VII Health Professions Training Programs.--The health
    professions training programs administered by the HRSA are the only
    Federal initiatives designed to address the longstanding under
    representation of minorities in health careers. HRSA's own report,
    ``The Rationale for Diversity in the Health Professions: A Review of
    the Evidence,'' found that minority health professionals
    disproportionately serve minority and other medically underserved
    populations, minority populations tend to receive better care from
    practitioners of their own race or ethnicity, and non-English speaking
    patients experience better care, greater comprehension, and greater
    likelihood of keeping follow-up appointments when they see a
    practitioner who speaks their language. Studies have also demonstrated
    that when minorities are trained in minority health professions
    institutions, they are significantly more likely to: (1) serve in
    medically underserved areas; (2) provide care for minorities; and (3)
    treat low-income patients.
        Minority Centers of Excellence (COE).--The purpose of the COE
    program is to assist schools, like Charles Drew University, that train
    minority health professionals, by supporting programs of excellence.
    The COE program focuses on improving student recruitment and
    performance; improving curricula and cultural competence of graduates;
    facilitating faculty and student research on minority health issues;
    and training students to provide health services to minority
    individuals by providing clinical teaching at community-based health
    facilities. For fiscal year 2011, the funding level for COE should be
    $33.6 million.
        Health Careers Opportunity Program (HCOP).--Grants made to health
    professions schools and educational entities under HCOP enhance the
    ability of individuals from disadvantaged backgrounds to improve their
    competitiveness to enter and graduate from health professions schools.
    HCOP funds activities that are designed to develop a more competitive
    applicant pool through partnerships with institutions of higher
    education, school districts, and other community based entities. HCOP
    also provides for mentoring, counseling, primary care exposure
    activities, and information regarding careers in a primary care
    discipline. Sources of financial aid are provided to students as well
    as assistance in entering into health professions schools. For fiscal
    year 2011, the HCOP funding level of $35.6 million is suggested.
    National Institutes of Health's (NIH) Contribution to Fighting Health
            Disparities
        National Institute on Minority Health and Health Disparities
    (NIMHD) .--The NIMHD is charged with addressing the longstanding health
    status gap between under-represented minority and nonminority
    populations. The NIMHD helps health professional institutions to narrow
    the health status gap by improving research capabilities through the
    continued development of faculty, labs, telemedicine technology and
    other learning resources. The NIMHD also supports biomedical research
    focused on eliminating health disparities and developed a comprehensive
    plan for research on minority health at NIH. Furthermore, the NIMHD
    provides financial support to health professions institutions that have
    a history and mission of serving minority and medically underserved
    communities through the COE program and HCOP. For fiscal year 2011,
    $500 million is recommended for NIMHD to support these critical
    activities.
                Research Centers At Minority Institutions (RCMI)
        RCMI at the National Center for Research Resources (NCRR) has a
    long and distinguished record of helping institutions like The Charles
    Drew University develop the research infrastructure necessary to be
    leaders in the area of translational research focused on reducing
    health disparities research. Although NIH has received some budget
    increases over the last 5 years, funding for the RCMI program has not
    increased by the same rate. Therefore, the funding for this important
    program grow at the same rate as NIH overall in fiscal year 2011.
                Extramural Facilities Construction
        Mr. Chairman, one issue that sets The Charles Drew University and
    many minority-dedicated institutions apart from the major universities
    of this country is the facilities where research takes place. The need
    for research infrastructure at our Nation's minority serving
    institutions must also remain strong to maximize efforts to reduce
    health disparities. The current authorization level for the Extramural
    Facility Construction program at the NCRR is $250 million. The law also
    includes a 25 percent set-aside for ``Institutions of Emerging
    Excellence'' (many of which are minority institutions) for funding up
    to $50 million. In fiscal year 2011, we respectfully request.
    Department of Health and Human Services' Office of Minority Health
            (OMH)
        Specific programs at OMH include assisting medically underserved
    communities, supporting conferences for high school and undergraduate
    students to interest them in health careers, and supporting cooperative
    agreements with minority institutions for the purpose of strengthening
    their capacity to train more minorities in the health professions. For
    fiscal year 2011, I recommend a funding level of $75 million for OMH to
    support these critical activities.
    Strengthening Historically Black Graduate Institutions--Department of
            Education
        The Department of Education's Strengthening Historically Black
    Graduate Institutions program (title III, part B, section 326) is
    extremely important to MMC and other minority serving health
    professions institutions. The funding from this program is used to
    enhance educational capabilities, establish and strengthen program
    development offices, initiate endowment campaigns, and support numerous
    other institutional development activities. In fiscal year 2011, an
    appropriation of $75 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
    Conclusion
        Despite all the knowledge that exists about racial/ethnic, socio-
    cultural and gender-based disparities in health outcomes, the gap
    continues to widen. Not only are minority and underserved communities
    burdened by higher disease rates, they are less likely to have access
    to quality care upon diagnosis. As you are aware, in many minority and
    underserved communities preventative care and research are inaccessible
    either due to distance or lack of facilities and expertise. As noted
    earlier, in just one underserved area, South Los Angeles, the number
    and distribution of beds, doctors, nurses and other health
    professionals are as parlous as they were at the time of the Watts
    Rebellion, after which the McCone Commission attributed the so-named
    ``Los Angeles Riots'' to poor services--particularly access to
    affordable, quality healthcare. The Charles Drew University has proven
    that it can produce excellent health professionals who ``get'' the
    mission--years after graduation they remain committed to serving people
    in the most need. But, the university needs investment and committed
    increased support from Federal, State, and local governments and is
    actively seeking foundation, philanthropic, and corporate support.
        Even though institutions like The Charles Drew University are
    ideally situated (by location, population, community linkages, and
    mission) to study conditions in which health disparities have been well
    documented, research is limited by the paucity of appropriate research
    facilities. With your help, the Life Sciences Research Facility will
    translate insight gained through research into greater understanding of
    disparities and improved clinical outcomes. Additionally, programs like
    Title VII Health Professions Training programs will help strengthen and
    staff facilities like our Life Sciences Research Facility.
        We look forward to working with you to lessen the huge negative
    impact of health disparities on our Nation's increasingly diverse
    populations, the economy and the whole American community.
        Mr. Chairman, thank you again for the opportunity to present
    testimony on behalf of The Charles Drew University. It is indeed an
    honor.
                                     ______

       Prepared Statement of the Children's Environmental Health Network

        The Children's Environmental Health Network (CEHN) appreciates the
    opportunity to support fiscal year 2011 appropriations for activities
    that protect children from environmental hazards. CEHN appreciates the
    wide range of needs that you must consider for funding. We urge you to
    give priority to those programs that 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.
        CEHN was created to promote a healthy environment and to protect
    the fetus and the child from environmental health hazards. Every day,
    children are exposed to a mix of chemicals, most of them untested for
    their effects on developing systems. In general, children have unique
    vulnerabilities and susceptibilities to toxic chemicals. In some cases,
    an exposure which may cause little or no harm to an adult may lead to
    irreparable damage to a child. Thus it is vital that the Federal
    programs and activities that protect children from environmental
    hazards receive adequate resources.
        Global Climate Change and Public Health.--We strongly urge the
    subcommittee to designate $50 million for the Department of Health and
    Human Services (HHS) to help the public prepare for and adapt to the
    potential health effects of global climate change in fiscal year 2011.
    Global climate change presents major challenges to public health.
    Children will be the first and worst hit by climate change. Young
    children are almost 85 percent of the estimated 150,000+ climate
    change-related deaths/year that are already occurring in low-income
    nations, according to the World Health Organization. Children in
    communities that are already disadvantaged will be the most harmed.
    Recent studies have detailed the multiple ways in which climate change
    may harm children. It is imperative that the Federal Government
    undertake efforts to mitigate and adapt to climate change.
        Centers for Disease Control and Prevention (CDC) and the National
    Center for Environmental Health (NCEH).--As the Nation's leader in
    health promotion and disease prevention the CDC should receive top
    priority in Federal funding. CEHN is grateful for your support in the
    past and urges you to support a funding level of $8.8 billion for CDC's
    core programs in fiscal year 2011.
        CEHN is supportive of all NCEH programs and especially its efforts
    to continue and expand its biomonitoring program and to continue its
    national report card on exposure information. A vital CDC
    responsibility in pediatric environmental health is to assist in
    filling the major information gaps that exist about children's
    exposures. CEHN believes it is especially critical for the NCEH to
    gather and publish expanded information in the report card on
    children's exposures.
        CEHN strongly supports increased funding for CDC's Environmental
    Health Laboratory, which allows us to measure with great precision the
    actual levels of more than 450 chemicals and nutritional indicators in
    people's bodies. This information helps public health officials to
    determine which population groups are at high risk for exposure and
    adverse health effects, assess public health interventions, and monitor
    exposure trends over time.
        Among its many recent accomplishments, CDC has funded three States
    for State biomonitoring activities. We enthusiastically support these
    State biomonitoring efforts, but were disappointed that another 21
    quality State proposals were turned down due to lack of funding.
        Unfortunately, the President's fiscal year 2011 budget would cut
    this program by $1.3 million. CEHN supports a $19.6 million increase
    for the Environmental Health Laboratory in fiscal year 2011: $10
    million to fund 7-10 grantees to conduct biomonitoring; $7.6 million
    for intramural activities such as increasing the number of chemicals
    CDC measures and improving quality assurance at the State laboratories
    awarded biomonitoring funds; and $2 million for the National Report on
    Biochemical Indicators of Diet and Nutrition in the U.S. Population.
        National Environmental Public Health Tracking Program.--The CDC's
    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. The Web-based National Environmental Public Health
    Tracking Network launched this past summer. CEHN strongly supports this
    program.
        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.
        To date, 24 grantees have received funds from the CDC for health
    tracking networks. Health officials in all States need integrated
    health and environmental data. We urge the subcommittee to provide $50
    million for the Health Tracking Program in fiscal year 2011.
        National Institute of Environmental Health Sciences (NIEHS).--The
    NIEHS is the leading Institute conducting research to understand how
    the environment influences the development and progression of human
    disease. Thus it 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 understanding
    childhood exposures that may not affect health until decades later.
        NIEHS's National Toxicology Program is the leading Federal program
    studying the toxicity of environmental agents in our environment; a
    major focus of this program is endocrine disrupting chemicals. NIEHS is
    studying the health effects of global climate change. The Institute has
    taken the lead among Federal agencies to develop a comprehensive
    research plan to respond to the significant consequences that climate
    change is expected to have on human health. CEHN asks you to provide
    $779.4 million for NIEHS in fiscal year 2011.
        Children's Environmental Health Research Centers of Excellence.--
    The Children's Environmental Health Research Centers, jointly funded by
    the Environmental Protection Agency (EPA) and NIEHS, play a key role in
    providing the scientific basis for protecting children from
    environmental hazards. With their modest budgets (unchanged over more
    than 10 years), these centers generate valuable research. A unique
    aspect of these centers 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.
        The scientific output of these centers has been outstanding. The
    Congress recognized this last year, when it supported increased
    funding, resulting in the upcoming addition of a child care component
    and additional research. These goals call for a continued effort, yet
    the administration's fiscal year 2011 budget proposal did not continue
    this funding. We strongly urge that the subcommittee reinstate these
    funds and direct NIEHS to sustain this effort.
        Unfortunately, almost all of the existing 12 centers are currently
    operating on no-cost extensions and only 5 of the existing centers are
    to be renewed. If centers are shuttered, we will lose access to
    valuable populations such as children with asthma or children growing
    up with pesticide exposure in farm communities. We will lose the
    ability to learn about issues like early puberty concerns, exposures in
    school settings, and pre-adolescent and adolescent outcomes.
        National Children's Study (NCS).--NCS is examining the effects of
    environmental influences on the health and development of more than
    100,000 children across the United States, following them from before
    birth until age 21. This landmark study--involving a consortium of
    agencies--will form the basis of child health guidance, interventions,
    and policy for generations to come. This study may be the only means
    that we will have to understand the links between exposures and the
    health and development of children and to identify the antecedents for
    a healthy adulthood.
        We urge the subcommittee to assure stable support for this study,
    recognizing that the necessary components of the study are resource
    intensive. It is vital, however, that this study proceed and also
    guarantee that scientists, clinicians, and policy makers will have a
    complete archive of the study's exposure measurements.
        A study of this scope calls for the participation of multiple
    agencies. We urge the subcommittee to assure that the NCS remains a
    collaborative study that retains on its original environmental focus,
    responsive to its mission and to the lead agencies, in and out of the
    National Institutes of Health.
        CEHN also asks the subcommittee to direct that protocols are in
    place for measuring exposures in child care and school settings. 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 (PEHSUs).--Funded by
    the ATSDR and the EPA, the PEHSUs form a valuable resource network,
    with a center in each of the U.S. Federal regions. PEHSU professionals
    provide medical consultation to healthcare professionals on a wide
    range of environmental health issues. PEHSUs also provide information
    and resources to school, child care, health and medical, and community
    groups. PEHSUs assist policymakers by providing data and background on
    local or regional environmental health issues and implications for
    specific populations or areas. These centers, all based in
    universities, have done tremendous work on very limited budgets. We
    urge the subcommittee to fully fund ATSDR's portion of this program's
    fiscal year 2011 budget of $1.8 million.
        Environmental Health in Schools.--Each school day, about 20 percent
    of the total U.S. population spend a full week inside schools.
    Unfortunately, many of our school facilities are shoddy or ``sick''
    buildings whose environmental conditions harm children's health and
    undermine attendance, achievement, and productivity.
        No agency is authorized to intervene to protect children from
    environmental hazards in schools. Thus, every day we require our
    children to spend hours in an environment where they and their parents
    have no options, alternatives or recourse if the environment is not
    healthy. Thus, CEHN urges the subcommittee to provide full funding for
    the aspects of the Clean, Green and Healthy Schools Initiative in its
    jurisdiction. Agencies need adequate resources to assure their
    participation in the vital cross-agency work of this initiative.
        A formal partnership between HHS, the Department of Education, and
    EPA to coordinate their pediatric environmental health efforts would
    leverage resources and be beneficial for children's health and
    research. Providing resources for the newly re-vitalized Interagency
    Task Force on Children's Environmental Health would support such a
    partnership.
        Environmental Health in Child Care Settings.--60 percent of
    preschoolers--13 million children--are in child care. This youngest and
    most vulnerable population can enter care as early as 6 weeks of age
    and be in care for more than 40 hours per week. Yet little is known
    about the environmental health status of these centers. CEHN is working
    to correct these gaps.
        We urge the subcommittee to bring the child care environment into
    the Clean, Green and Healthy Schools Initiative by providing additional
    resources and direction focused on this important environment.
        We ask the subcommittee to direct the HHS Assistant Secretary for
    Children and Families to report on the Administration for Children and
    Families activities that protect children from environmental hazards in
    child care 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 CEHN 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

        On behalf of the Cystic Fibrosis Foundation and the 30,000 people
    with cystic fibrosis (CF), we are pleased to submit the following
    testimony regarding fiscal year 2010 appropriations for cystic
    fibrosis-related research at the National Institutes of Health (NIH)
    and other agencies.

                                    ABOUT CF

        CF is a life-threatening genetic disease for which there is no
    cure. The bodies of people with CF produce abnormally thick, sticky
    mucus that clogs the lungs, results in fatal lung infections and
    obstructs the pancreas, making it difficult for patients to absorb
    nutrients from food. Since its founding, the Cystic Fibrosis Foundation
    has maintained its focus on promoting research and improving treatments
    for CF. More than thirty drugs are now in development to treat CF; some
    treat the basic defect of the disease, while others target its
    symptoms. Through the research leadership of the Cystic Fibrosis
    Foundation, the life expectancy of individuals with CF has been boosted
    from less than 6 years in 1955 to 37 years today. Although life
    expectancy has improved dramatically, we continue to lose young lives
    to this disease. In the past 5 years, the Cystic Fibrosis Foundation
    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
    rapidly and efficiently discover and develop new CF treatments aimed at
    controlling and 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 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) in 2009.
    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 generated by the doubling of funds and the infusion from ARRA.
        The flat-funding of the NIH since 2003 has decreased purchasing
    power, limiting the pursuit of critical research. The Cystic Fibrosis
    Foundation joins the Coalition for Health Funding to recommend all
    health discretionary spending be increased $67.1 billion in fiscal year
    2011, or $9.3 billion more than the fiscal year 2010 levels. This
    increased investment will help maintain the NIH's ability to fund
    essential biomedical research today that will provide the care and
    cures of tomorrow. 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 people's lives.

              STRENGTHENING CLINICAL RESEARCH AND DRUG DEVELOPMENT

        The Cystic Fibrosis Foundation has been recognized for its unique
    research approach which encompasses everything from 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 thirty potential therapies
    which are being examined to treat people with CF. As a prime example,
    in February 2010, Caystonr a new much-needed antibiotic that combats
    recurrent lung infections, arrived in the hands of people with CF. This
    new treatment is a direct result of the Foundation's innovative
    research agenda, advancing from bench to bedside through the
    Foundation's research program which speeds the creation of new CF
    therapies. Our successes, and specifically our Therapeutics Development
    Network discussed below, can serve as a map for the development of new
    treatments for other diseases.
        The Foundation is a leader in creating a clinical trials network to
    achieve greater efficiency in clinical investigation. Because the CF
    population is small, a higher proportion of people with the disease
    must partake in clinical trials than in most other diseases. This
    unique challenge prompted the Foundation to streamline our clinical
    trials processes. As a result, research conducted by the Foundation is
    more efficient than ever before and we are a model for other disease
    groups. We applaud the efforts by the Nation's health agencies to
    encourage greater efficiency in clinical research and we are hopeful
    that the subcommittee will direct the national health agencies to pay
    special attention to advances in treatment methods and mechanisms for
    translating basic research across Institutes into therapies that can
    benefit patients.
    Development of Rare Disease Research Networks
        The subcommittee should direct the NIH and other agencies to
    allocate additional funds for innovative therapeutics development
    models including the Therapeutics for Rare and Neglected Diseases
    (TRND) and Cures Acceleration Network (CAN) programs as well as for
    clinical research to meet the demand for testing promising new
    therapies for CF and other diseases. Support should also be directed
    toward the continuation of other rare disease research networks, such
    as the NIH's pediatric liver disease consortium.
        The CF Foundation'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 the TDN's
    centralization of data management and analysis and data safety
    monitoring in the TDN will be useful in designing clinical trial
    networks for other diseases. Dr. Francis Collins, Director of the NIH,
    has specifically cited the TDN as an exemplar for TRND. Coupled with
    the newly established CAN, the time between discovery and development
    of drugs and therapies can be accelerated if these programs are fully
    funded.
    Providing for the U.S. Food and Drug Administration (FDA)
        We urge the subcommittee to increase funding for the FDA to ensure
    that the Agency has the necessary resources and funding to effectively
    evaluate new and emerging treatments. In order to be effective, the FDA
    needs not only an adequate number of reviewers of new treatments, but
    also those with the appropriate skills and expertise, particularly for
    rare diseases like CF. Additional support for the FDA through increased
    funding not only assures that the Nation has a safe and effective
    supply of drugs and devices, but also that the agency can give the
    necessary attention to reviewing treatments that treat small
    populations but serve specific unmet medical needs, such as Caystonr.
        The CF Foundation applauds the appointment of Dr. Anne Pariser as
    the new Associate Director for Rare Diseases in the FDA's Center for
    Drug Evaluation and Research's Office of New Drugs. We are pleased to
    see this new position held by such a capable and competent
    administrator. Similarly, we applaud the regulatory science initiative
    formed by the NIH and the FDA with the goal of accelerating the
    development and use of new approaches to evaluate drug safety,
    efficacy, and quality and urge the subcommittee to strongly support
    this type of collaboration. Support for coordination between new
    programs like TRND and CAN throughout the national health agencies
    leverages the Federal investment in new research, facilitating swifter
    development and delivery of new medical treatments.
    Supporting Translational Research and Investigators
        A significant discrepancy persists between the first award funding
    granted to clinical laboratory investigators and that granted to basic
    laboratory investigators. 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.
    The Clinical and Translational Science Awards (CTSA)
        We urge the NIH to enhance the Clinical and Translational Science
    Awards (CTSA), a program designed to transform the way in which
    clinical and translational research is conducted. Such an increased
    emphasis on clinical translation can enable researchers to provide new
    treatments more efficiently to patients. For example, at Seattle
    Children's Hospital, a CTSA program has been instrumental in
    identifying best practices for efficient clinical trial participation
    and improving clinical outcomes in care for CF. Tremendous effort has
    brought institutions together to rally around this program and similar
    programs at other institutions, yet current funding levels make it
    difficult for the full complement of programs to be funded.
    Additionally, key to the success of the CTSAs is the development of
    cost-sharing mechanisms like the General Clinical Research Centers
    (GCRC), which allowed institutes to reduce their research budgets by
    having investigators use the GCRC when clinical care was made available
    at no additional cost. In order to maximize the potential of the CTSA,
    multiple institutes within the NIH must be able to provide financial
    resources for critical programs such as this.
    Alterative Models for Institutional Review Boards (IRB)
        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
        An additional impediment in our effort to accelerate the
    development of new therapies is the Social Security Administration's
    current Supplemental Security Income (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. S. 1674, the
    Improving Access to Clinical Trials Act of 2009, would allow the Social
    Security Administration to disregard any income received from
    compensation for clinical trials when determining eligibility for
    programs like SSI. Support from the subcommittee on resolving this
    disincentive toward clinical research is appreciated.
    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. 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

        The Cystic Fibrosis Foundation'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.
    Opportunities in Animal Models
        The Cystic Fibrosis Foundation 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 the Cystic Fibrosis Foundation, 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, causes an intense inflammatory
    response. The Cystic Fibrosis Foundation enthusiastically supports
    investments by the NIH to gain a greater understanding of neutrophil-
    driven inflammatory responses, 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 Common Fund
    priorities. 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 centers must
    be integrated. To address this, the Cystic Fibrosis Foundation 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. The CF Foundation 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. 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. 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. The CF Foundation 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 the CF Foundation 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 the Cystic Fibrosis Foundation, we thank the subcommittee
    for its consideration.
                                     ______

       Prepared Statement of Children and Adults with Attention-Deficit/
                             Hyperactivity Disorder

    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 130,000 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 9,364 individual inquiries during the last year on
            17,115 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 4,100 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 2011 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.
        Both the National Institutes of Health Consensus Conference on AD/
    HD (Nov. 1998) and the Centers for Disease Control and Prevention
    Conference on Public Health and AD/HD (Sept. 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.\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.
    ---------------------------------------------------------------------------
        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.\6\ ``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 over 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.
    ---------------------------------------------------------------------------
        \6\ Barkley, R.A., Murphy, K.R., & Fischer, M. (2008). ADHD in
    Adults: What the Science Says. New York: The Guilford Press.
        \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.
    ---------------------------------------------------------------------------
        Last year, the AD/HD line item was funded at $1.751 million. We are
    requesting a $400,000 increase in the AD/HD line item, which will
    result in a $200,000 increase in the NRC. Historically, half of the
    increase to the AD/HD line item has been used to fund research on AD/
    HD. The $200,000 increase to the NRC will allow the NRC to further
    develop its outreach to the African-American and Hispanic-Latino
    communities, and most importantly during this current economic climate
    to initiate an employment information specialist service.
    Requested Report Language for Fiscal Year 2011
        The subcommittee continues to support the activities of the CDC's
    NCBDDD and the National Resource Center (NRC) on AD/HD and has provided
    $2,151,000 to continue this support, including $1,075,500 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 most importantly during this current economic
    climate, provides support for a health information specialist focused
    on employment to assist 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 (CHSR) 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 3,800 researchers, scientists, and policy experts and 150
    organizations that produce and use health services research.
        Healthcare in the United States has the potential to dramatically
    improve people's health, but often falls short and costs too much.
    Health services research is used to understand how better to finance
    the costs of care, measure and improve the quality of care, and improve
    coverage and access to affordable services. It provides patients,
    providers, payers, and policymakers with the tools needed to make
    healthcare:
      --Affordable by decreasing cost growth to sustainable levels.
      --Efficient by decreasing waste and overpayment and monitoring the
            cost-effectiveness of care.
      --Safe by decreasing preventable medical errors, monitoring public
            health, and improving preparedness.
      --Effective by evaluating programs and outcomes and promoting
            evidence-based innovations.
      --Equitable by eliminating disparities in health and healthcare.
      --Accessible, by connecting people with the healthcare they need when
            they need it.
      --Patient-centered by increasing patient engagement in and
            satisfaction with the care received.
        Indeed, health services research has been changing the face of U.S.
    healthcare, uncovering critical challenges confronting 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
    found that disparities and lack of access to care in rural and inner
    cities result in poorer health outcomes. And it demonstrated 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.
        But health services research does not just lift the veil on the
    problems plaguing U.S. healthcare; it also seeks ways to address them.
    Health services research offers guidance on implementing and making the
    best use of health information technology and getting the best care at
    the best value. Health services research framed the debate over
    healthcare reform in Massachusetts--forming the basis for that State's
    2006 health reform legislation--and was instrumental in shaping
    comprehensive national health reform through The Patient Protection and
    Affordable Care Act. As health reform is implemented over the next few
    years, health services research will be needed more than ever to
    monitor and evaluate the new law's impact on the healthcare system and
    the health status of Americans. Do Americans have better access to
    healthcare? Are the measures projected to bend the healthcare cost
    curve downward having the desired effect? Are patients more engaged in
    healthcare decisionmaking? Is care better coordinated across providers?
    Health services research will provide the answers to these and other
    important questions.
        For the last 7 years, the Coalition has collected data to track the
    Federal Government's expenditures for health services research and
    health data. Information provided to us by the principal funders of
    health services research and data--including the Agency for Healthcare
    Research and Quality (AHRQ), the National Institutes of Health (NIH),
    the Centers for Disease Control and Prevention (CDC), and the Centers
    for Medicare and Medicaid Services (CMS)--indicates that the field of
    health services research and data has operated with diminished
    purchasing power for years. Up until 2008, overall spending on
    healthcare continued to rise faster than the rate of inflation--from
    $1.4 trillion in 2000 to nearly $2.3 trillion in 2008. Despite the
    recent increase in Federal funding for health services research and
    data--$1.8 billion in fiscal year 2009--the total Federal investment
    still accounted for only 0.078 percent of the $2.3 trillion we spend on
    healthcare annually.
        The CHSR greatly appreciates the subcommittee's recent efforts to
    increase the Federal investment in health services research and
    comparative effectiveness research through the fiscal year 2010 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-ever single funding increase in health services
    research. With comprehensive health reform now a reality, we ask the
    subcommittee to continue strengthening 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. Recent years' steady, incremental increases for
    AHRQ's Effective Health Care Program, as well as the $300 million
    provided to AHRQ in the American Recovery and Reinvestment Act, have
    helped 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 has languished as funding for AHRQ's base has remained
    relatively flat. To balance the recent investments in AHRQ's
    comparative effectiveness research, we recommend that:
      --AHRQ's broader health services research portfolio should not be
            sacrificed for the sole benefit of comparative effectiveness
            research. The entirety of the President's requested budget
            increase will support ``patient-centered health research''
            (i.e., comparative effectiveness research) while funding for
            programs in AHRQ's broader research portfolio are cut or flat-
            funded to support a more robust comparative effectiveness
            research portfolio. The full spectrum of health services
            research on healthcare cost, quality, and access is essential
            to ensure that research on ``what works'' is implemented in
            ways that support broader health reform efforts.
      --Congress should continue to place priority on investigator-
            initiated research and should target funding for innovative,
            competitive grants in fiscal year 2011. The President's
            proposed budget does not fund new investigator-initiated
            research grants at AHRQ in fiscal year 2011. The Coalition is
            grateful to the subcommittee for its leadership in recognizing
            the value of investigator-initiated research at AHRQ. The
            Coalition requests that you continue this investment in fiscal
            year 2011 and sustain the momentum for competition and
            innovation you have cultivated over several years.
      --Congress should target more funding for pre- and postdoctoral
            training grants to increase capacity to respond to growing
            public and private sector demand for health services research.
            At the direction of Congress, AHRQ doubled its investment in
            training grants for the next generation of researchers in the
            last year. Still, training grants for new researchers fall far
            short of what is needed across all disciplines to meet growing
            public and private sector demand for health services research.
            As the lead agency for health services research, AHRQ requires
            more funding to develop the next generation of health services
            researchers--both physician and nonphysician researchers.
        While targeted funding increases in recent years have moved AHRQ in
    the right direction, more core funding is needed to help AHRQ fulfill
    all aspects of 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 supporting the President's
    requested funding level of $611 million.
    Centers for Disease Control and Prevention (CDC)
        Housed within the 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. With the
    subcommittee's leadership in securing steady and sustained funding
    increases for NCHS over the last 3 fiscal years, NCHS is rebuilding
    after years of underinvestment that 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. We join the Friends of
    NCHS--a coalition of more than 250 health professional, research,
    consumer, industry, and employer organizations that support the
    agency--in endorsing the President's fiscal year 2011 request of $162
    million, a funding level that will build on your previous investments
    and put the agency on track to become a fully functioning, 21st
    century, national statistical agency.
        The Patient Protection and Affordable Care Act recognizes the need
    for linking the medical care and public health delivery systems by
    authorizing a new CDC research program to study the delivery of public
    health services. If funded in fiscal year 2011, this program will
    support the examination of evidence-based practices relating to
    prevention; analyze the translation of interventions from academic to
    real-world settings; and identify effective strategies for organizing,
    financing, or delivering public health services in real-world community
    settings by, for example, comparing State and local health department
    structures and systems in terms of effectiveness and costs. The
    Coalition urges you to appropriate $50 million for this important
    program in fiscal year 2011, enabling us to study ways to improve the
    efficiency and effectiveness of public health service delivery.
        In addition, the Coalition urges you to provide the CDC's important
    Public Health Research portfolio and Prevention Research Centers--a
    network of academic health centers that conduct public health
    research--with at least $35 million for Public Health Research and at
    least $35 million for Prevention Research Centers in fiscal year 2011.
    These programs--which seek ways to develop, translate, and disseminate
    research to address obesity, diabetes, and heart disease; healthy aging
    and youth development; cancer risk; and health disparities--have been
    virtually flat-funded since fiscal year 2006. At a time when chronic
    diseases persist as the primary drivers of escalating healthcare costs,
    greater investment in public health research is needed to identify
    evidence-based solutions to curbing the prevalence of these diseases.
    Centers for Medicare and Medicaid Services (CMS)
        Steady funding decreases for the Office of Research, Development
    and Information, together with an increasingly earmarked budget, have
    hindered CMS's ability to meet its statutory requirements and conduct
    new research to strengthen public insurance programs--including
    Medicare, Medicaid, and the Children's Health Insurance Program--which
    together cover nearly 100 million Americans and comprise 45 percent of
    America's total health expenditures. As these Federal entitlement
    programs continue to pose significant budget challenges for both
    Federal and State governments, it is critical that we adequately fund
    research to evaluate the programs' efficiency and effectiveness and
    seek ways to manage their projected spending growth.
        The Coalition supports an increase in CMS's discretionary research
    and development budget from $36 in fiscal year 2010 to a base fiscal
    year 2011 funding level of $47 million, consistent with the President's
    request. This funding is a critical down payment to help CMS recover
    lost resources and restore research to evaluate its programs, analyze
    pay for performance and other tools for updating payment methodologies,
    and further refine service delivery methods.
        In addition, the Coalition supports the President's fiscal year
    2011 request of $110 million for a new data improvement initiative at
    CMS. This investment would enhance the quality and timeliness of data,
    support health reform initiatives such as value-based purchasing and
    comparative effectiveness research, improve payment accuracy, and
    enhance systems security. The Coalition supports the President's
    efforts to improve data quality, timeliness, and access and encourages
    Congress to appropriate funding so that the research community will be
    able to access CMS's valuable data to enhance these Federal programs
    and ultimately reduce mandatory spending.
    NIH
        NIH reported that it spent $1.1 billion on health services research
    in fiscal year 2009--roughly 3.6 percent of its entire budget--making
    it the largest Federal sponsor of health services research. For fiscal
    year 2011, the Coalition recommends a health services research base
    funding level of at least $1.27 billion--3.6 percent of the $35 billion
    sought by the broader health community for NIH. The Coalition believes
    that NIH should increase the proportion of its overall funding that
    goes to health services research from 3.6 to 5 percent to ensure 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. With important health reforms
    now undergoing implementation, health services research will continue
    to yield valuable scientific evidence in support of improved quality,
    accessibility, and affordability of healthcare. We urge the
    subcommittee to accept our fiscal year 2011 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 2011 appropriations for the Low-Income Home
    Energy Assistance Program (LIHEAP).
        The Governors appreciate the subcommittee's continued support for
    LIHEAP, and we thank you for providing $5.1 billion in fiscal year 2010
    funding for the program. The Governors recognize the considerable
    fiscal challenges facing the subcommittee this year. However, as the
    number of households seeking heating and cooling assistance continues
    to increase nationwide, we urge you to provide fiscal year 2011 funding
    for the core LIHEAP block grant program at least at the most recent
    authorized level of $5.1 billion, as well as provide sufficient
    contingency funds to address unforeseen energy emergencies. Providing
    this funding level through the block grant program provides the
    certainty that States need to implement an effective program.
        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 newly unemployed, and families with young children.
    Under this targeted program, the majority of households receiving
    assistance have incomes of less than $8,000 a year. These households
    have the highest energy burden, spending more than 16 percent of their
    income on home energy compared to 3 percent for non-low-income
    households.
        This disproportionate energy burden experienced by vulnerable low-
    income families continues. In recent years, the increase in the cost of
    home energy has far outpaced both the rate of inflation and the
    increase in household income.\1\ The share of income that elderly
    households spend on housing costs and out-of-pocket healthcare
    expenditures has increased substantially in the last two decades.\2\
    LIHEAP is an effective tool for helping these households better manage
    the financial pressures of unaffordable home energy costs, through
    assistance in paying bills as well as making their homes and heating
    systems safer and more efficient.
    ---------------------------------------------------------------------------
        \1\ Short and Long-Term Perspectives: The Impact on Low-Income
    Consumers of Forecasted Energy Price Increases in 2008 and a Cap-and-
    Trade Carbon Policy in 2030, Oak Ridge National Laboratory, December
    2007.
        \2\ Recipiency Targeting Analysis for Elderly and Young Child
    Households, prepared for the Office of Community Services' Division of
    Energy Assistance by APPRISE Incorporated, December 2008.
    ---------------------------------------------------------------------------
        While some national economic reports are hopeful, the current
    situation remains challenging for these low-income households as the
    costs of essential household expenses including home energy and food
    remain high. This is particularly true in the Northeast where a greater
    percentage of households use delivered heating fuels, such as home
    heating oil, propane and kerosene, than in any other region of the
    country. These households are more vulnerable to price volatility,
    making it more difficult for families to manage their household
    budgets. Households using deliverable fuels tend to have an extremely
    high energy burden, with historically higher energy bills than those
    using other heating sources. The average annual heating bill for all
    LIHEAP recipients was $717 in 2007. However, the average annual heating
    bill for households using home heating oil was $1,686, and the average
    heating bill for propane users was $1,052.\3\ This pattern continues.
    Even as the price of some home energy prices stabilize, the Energy
    Information Administration finds that home heating oil prices have
    increased 20 percent more than last year.\4\ In addition, households
    that rely upon delivered fuels do not have the benefit of a program
    comparable to a utility service shut-off moratorium. If a household
    cannot afford to purchase the home heating fuel, the delivery truck
    simply does not come.
    ---------------------------------------------------------------------------
        \3\ LIHEAP Home Energy Notebook for Fiscal Year 2007, U.S.
    Department of Health and Human Services, Administration for Children
    and Families, Office of Community Services, Division of Energy
    Assistance, June 2009.
        \4\ Short-Term Energy Outlook, Energy Information Administration,
    March 2010.
    ---------------------------------------------------------------------------
        The number of households receiving LIHEAP assistance continues to
    reach record levels. According to the National Energy Assistance
    Directors' Association (NEADA), 8.3 million households received heating
    assistance in 2009, compared to 6.1 million in 2008. States expect that
    number to grow to more than 9.5 million in 2010. Many of these
    applicants have never requested help before, but are facing
    extraordinary economic hardship due to increased unemployment and
    layoffs. Yet, this is only a small portion of the eligible households.
        As spring approaches and utility shut-off moratoria end, too many
    families are in danger of having their utility service terminated for
    nonpayment. According to NEADA, approximately 4.3 million households
    were shut off from power in fiscal year 2009 up from 4.1 million in
    2008. In fiscal year 2009 approximately 12.5 million households were at
    least 30 days behind in their utility bills. The effects on these
    vulnerable households can be deadly. Numerous studies have found that
    the elderly and very young children are at risk for serious health
    consequences from prolonged exposure to home temperatures that are
    either too cold in the winter or too hot in the summer.
        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
    at least $5.1 billion in regular block grant funding for LIHEAP in
    fiscal year 2011 as well as sufficient 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 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 Corporation for Public Broadcasting

        Chairman Harkin, Ranking Member Cochran, and members of the
    subcommittee, thank you for allowing me to submit testimony on behalf
    of our Nation's public media system.
        As you know, the Corporation for Public Broadcasting (CPB), a
    private, nonprofit corporation created by the Public Broadcasting Act
    of 1967, is the steward of the Federal Government's investment in
    public broadcasting. We support the operations of more than 1,100
    locally owned and operated public television and radio stations
    nationwide. Throughout the United States, public broadcasting, or what
    should more accurately be called ``public media,'' engages citizens on-
    air, on-line, and on the ground with information they can use to
    improve their lives and strengthen their local communities. As
    commercial media becomes increasingly consolidated, a key strength of
    public media remains its design: a decentralized set of stations, each
    with deep local roots and maintaining individual service strategies
    tailored to the unique needs of its local community.
        Public broadcasting was born in an earlier moment of profound
    change and transition. In the 1950s and 1960s a new media technology
    was diffusing quickly: the television. Around it grew a movement to use
    the new medium, as well as existing radio technology, for educational
    purposes, and public broadcasting was born. Today, nearly a half-
    century after the signing of the Public Broadcasting Act, we are making
    a similar transition from public broadcasting to the ``Public Media
    2.0'' the President called for during his campaign. As we leverage our
    legacy to become a leader in the new and ever-changing media landscape,
    public media has focused its efforts through a strategic framework
    comprising the ``Three Ds'': Digital, Diversity, and Dialogue.
    Innovation on Digital Platforms
        As an outgrowth of its dedication to universal service, public
    media is embracing a range of digital delivery methods to reach all
    Americans, wherever and whenever they seek information. Because of its
    reach, its availability for free, and its unmatched efficiency in
    point-to-multipoint communications, over-the-air service remains an
    essential part of the public media portfolio. At the same time, public
    broadcasters are evolving into true multi-platform media entities by
    creating content and services, some related to and some entirely
    independent from broadcast content, that capitalize on the power of
    broadband and other digital technologies. For example:
      --KQED's (San Francisco) QUEST is a new multimedia series about the
            people behind Bay Area science and environmental issues which
            utilizes all of KQED's media platforms, educational resources
            and extraordinary partnerships, and includes a half-hour weekly
            HD television program, weekly radio segments, an innovative Web
            site and education guides.
      --Public Broadcasting Atlanta is developing Lens on Atlanta, an on-
            line portal that invites citizens to create and participate in
            blogs, wikis, forums, petitions, and surveys, and engages
            institutions and Government entities around Atlanta to listen
            and participate.
      --Many public radio stations have expanded the reach of their
            cultural programming by investing in and creating substantial
            Internet music services with significant audiences. Examples
            include WAMU's Bluegrass Country, WKSU's Folk Alley, WXPN's
            Xponential, and KCRW's Eclectic24.
        In addition to these local station efforts, public broadcasting's
    national organizations have been moving for some time to leverage the
    power of digital media. For example:
      --CPB is funding the creation of Local Journalism Centers, combining
            our and participating stations' resources for a ground-breaking
            approach to news gathering and distribution. The seven centers
            will form teams of multimedia journalists, who will focus on
            issues of particular relevance to each region, and their in-
            depth reports will be presented regionally and nationally via
            digital platforms, community engagement programs and
            broadcasts.
      --In October 2009, NPR initiated Argo, a new multi-media journalism
            project, funded by CPB and the Knight Foundation. The 2-year
            project is designed to strengthen public media's local
            journalism, build a significant online audience, and develop a
            common publishing platform that will better support public
            media's online needs. NPR is working with a dozen selected
            public television and radio stations to launch Web sites for
            each station that go in-depth on selected topics or
            ``verticals.''
      --In September 2008, PBS launched its PBS KIDS GO! video player,
            featuring hundreds of video clips and dozens of full-length
            episodes. Since launch, the site is averaging 1.3 million
            streams per week, and 9 million unique visitors a month. In
            December 2009 alone, children watched more than 87.5 million
            streams across the PBS KIDS family of Web sites, its highest
            total ever, putting it on track to be one of the most popular
            video sites in the world.
      --CPB is funding the development of the American Archive, which
            ultimately will restore, digitize, and preserve public
            broadcasting's deteriorating collections of local television
            and radio content. We expect to have 40,000 hours of local and
            national television and radio content available to the American
            public with in 18 months.
    Content That Reflects the Nation's Diversity
        Equally central to public media's universal service mission is
    providing individuals of every ethnicity and economic and social
    background, particularly those that are underserved by commercial
    media, relevant and engaging content. The ability to transmit multiple
    streams of digital programming over the air, combined with the nearly
    boundless capabilities of broadband, enable local and national public
    media entities to deliver content that truly reflects America's
    diversity. CPB is constantly expanding its relationships with diversity
    partners to both broaden its reach and to allow greater opportunities,
    on a variety of platforms, for underrepresented groups. Among these
    efforts:
      --CPB provides ongoing support to, among others: the National
            Minority Consortia, which provides seed money to producers of
            multicultural content; the Independent Television Service,
            which champions independently produced programming targeting
            underserved audiences; Koahnic Broadcast Corporation, the
            leader in bringing Native voices to Alaska and the nation
            through the only urban Native public radio station and its
            national production and distribution center (Native Voice One)
            in Albuquerque; and Radio Bilingue, the only national
            distributor of Spanish-language public radio programming, which
            is now developing a transmedia service in Los Angeles targeting
            a young, English-speaking, and highly diverse audience. We also
            funded the creation of Native Public Media in 2004 to build and
            advance Native access to, ownership of, and participation in
            media, especially radio.
      --In fiscal year 2010, we are creating within our multi-year PBS
            National Program Service agreement (which supports primetime
            and children's programming) a Diversity and Innovation Fund,
            which will support major content development projects that
            examine topics of interest to diverse audiences or that employ
            new, lower-cost production models.
      --CPB funds the National Black Programming Consortium's annual New
            Media Institute, a unique professional development program
            designed to introduce producers to the latest in digital media
            production, marketing, and distribution. The program includes a
            collaboration website where journalists can showcase their
            work, find and share public domain stock, share best practices,
            and brainstorm together on innovative future citizen media
            projects.
      --Through projects such as the Public Radio Talent Quest, CPB has
            identified a new generation of public broadcasting talent--
            Public Media 2.0 producers--who appeal to new audiences and
            produce multimedia content for a variety of platforms. For
            example, Glynn Washington, a winner of the Talent Quest,
            produces a new multimedia series, Snap Judgment, that combines
            his unique brand of storytelling with innovative technology to
            explore the decisions people make in moments of crisis.
    Services That Foster Dialogue Between Public Media and the American
            People
        Public media's localism remains more relevant than ever as
    commercial media are increasingly owned and operated by entities
    outside of their local communities--but the nature of our service to
    local communities is shifting in the digital age. Critical to public
    media's future will be its ability to collaborate and serve as an
    active resource and trusted partner to more diverse communities, in new
    ways. Public media entities are quickly adapting to the new paradigm.
    For example, as part of a comprehensive local/national response to the
    Nation's economic woes, CPB is supporting a number of in-depth
    community engagement projects, including:
      --Facing the Mortgage Crisis.--Fifty-seven stations are participating
            in this multi-million dollar national project designed to help
            the country's hardest-hit regions cope with an avalanche of
            mortgage foreclosures. Based on an extremely successful model
            developed by KETC-TV in St. Louis, stations are working with
            key community partners, such as United Way's 2-1-1 call
            centers, to create content on-air and online that helps
            families to avoid or mitigate home foreclosures.
      --Engaging Communities on the Economy.--CPB is supporting the work of
            37 stations working with partners to address other pressing
            economic issues, such as joblessness, hunger, loss of health
            insurance and family stress. These projects serve diverse
            audiences, from seniors to recent immigrants to teenagers.
    CPB's Requests for Appropriations
        Public media stations continue to evolve, both operationally and
    more importantly in the myriad ways they serve their communities.
    Stations are committed to reaching viewers and listeners on whatever
    platform they use--from smart phones to iPads to radios to TV sets. But
    new opportunities come with a cost. While stations can and will
    continue to adapt and thrive in the digital age, without sufficient
    support they cannot live up to the potential of the new technologies.
    As the Federal Communications Commission's recently-issued National
    Broadband Plan noted, ``Today, public media is at a crossroads . . .
    [it] must continue expanding beyond its original broadcast-based
    mission to form the core of a broader new public media network that
    better serves the new multi-platform information needs of America. To
    achieve these important expansions, public media will require
    additional funding.''
        CPB Base Appropriation (Fiscal Year 2013).--CPB requests a $604
    million advance appropriation for fiscal year 2013. Stations have been
    faced with flat CPB funding for the better part of the past decade, and
    the impact of this lack of an even inflationary increase (until fiscal
    year 2010) has been magnified by the economic conditions of the last
    few years. As public media seeks to make the transition to a truly
    digital enterprise, the Federal share of station funding has never been
    more critical. CPB distributes its advance appropriation in accordance
    with a statutory formula, under which almost 72 percent of funds go
    directly to local public television and radio stations, as well as
    discretionary support for the creation of programming for radio,
    television and new media and on projects that benefit the entire public
    broadcasting community. Added together, these efforts account for 95
    percent of the funds appropriated to CPB; we are limited by law to an
    administrative budget of 5 percent. The Federal appropriation accounts
    for under 15 percent of the entire cost of public broadcasting, but it
    is a vital core that leverages support from State and local
    governments, universities, businesses, foundations, and especially
    viewers and listeners of local public television and radio stations.
        CPB Digital (Fiscal Year 2011).--CPB requests $59.5 million in
    digital funding for fiscal year 2011. With this funding, CPB will
    continue its mission to fund stations' efforts to adapt to audience
    demands for educational, cultural and news and information content,
    regardless of platform. As the Administration noted in its fiscal year
    2011 budget request, while CPB Digital will continue to fund station
    ``equipment'' such as digital transmitters and translators, ``the
    majority of this funding will be utilized to fund projects to enhance
    multi-platform content creation, delivery and storage, such as the
    American Archive, which by converting content to digital format, will
    ensure that the vast archives of public broadcasting content will not
    be lost due to physical media deterioration.'' Though needs remain, as
    local stations' conversion to digital broadcasting ramps down, CPB
    Digital funding for broadcast equipment will continue to diminish, and
    the Department of Commerce's Public Telecommunications Facilities
    Program (PTFP) can resume its role as the primary Federal source for
    local station equipment funding.
        Ready To Learn (Fiscal Year 2011).--CPB is requesting $32 million
    in fiscal year 2011 for Ready To Learn (RTL), a Department of Education
    program with a nearly 20-year proven record of using the power and
    reach of public television's children's programming to raise the
    reading levels of children ages 2-8 who live in high-poverty
    environments. Today, Ready To Learn is a partnership between CPB, PBS,
    WGBH (Boston), WTTW (Chicago), Sesame Workshop, leading researchers and
    public television stations nationwide. We strongly disagree with the
    administration's proposed consolidation of RTL into an umbrella
    literacy program and instead believe that the difference this program
    has made on children's lives makes continued dedicated Federal support
    imperative. An appropriation of $32 million in fiscal year 2011 will
    enable RTL content and accompanying materials to be created and tested
    on a faster timeline, and will enable more communities to become
    involved in existing station-based outreach activities.
        Mr. Chairman and Ranking Member, thank you again for allowing CPB
    to submit this testimony. For nearly a half-century, public
    broadcasting has provided a safe place for millions of children to
    learn and unparalleled access to news and information; given voice to
    diverse points of view; and convened community dialogues. As the times
    have changed, so too have the technologies available to provide service
    to communities across our country. The challenge before us is how best
    to incorporate new capabilities into the public interest and service
    for all of our diverse citizenry, especially during these challenging
    economic times. With your continued support, we are ready to meet this
    challenge.
                                     ______

          Prepared Statement of the Corporation for Supportive Housing

        The Corporation for Supportive Housing (CSH) is a nonpartisan,
    nonprofit organization that helps communities build permanent
    supportive housing (PSH). We have offices in 12 States (California,
    Arizona, Texas, Illinois, Indiana, Ohio, Minnesota, Michigan, New
    Jersey, New York, Connecticut, and Rhode Island) and the District of
    Columbia and have a presence in several others. We work with
    communities and States to reorient systems and align resources to
    create permanent supportive housing and end and prevent chronic
    homelessness. Although many people experiencing homelessness may only
    need rental or income supports to become and stay housed, a significant
    and intractable subset of people experiencing homelessness need (in
    addition to rental assistance or affordable housing) intensive (wrap-
    around) supportive services such as substance use treatment, mental
    health services, healthcare to manage chronic diseases, and case
    management services.
        Most PSH providers receive at least a portion of the funds
    necessary to build or secure housing from the Department of Housing and
    Urban Development (HUD). Unfortunately, the Department of Health and
    Human Services has not made an equivalent commitment to funding the
    services component of PSH. As a result, PSH providers have few places
    to turn to for the funding needed to provide the wrap-around supportive
    services needed to keep chronically homeless individuals housed.
    Organizations and local government agencies patch together a
    combination of State, local, foundation and privately raised funds to
    pay for the vital social services chronically homeless populations must
    have to stay housed. These funds are often limited in amount and short-
    term in nature. In order to build the PSH units needed to end chronic
    homelessness, the Department of Health and Human Services must increase
    its investment in local permanent supportive housing projects. To this
    end, CSH recommends the following:
      --Allocate $120 million for services for people experiencing
            homelessness within the Programs of Regional and National
            Significance (PRNS) accounts of both SAMHSA's Center for Mental
            Health Services and Center for Substance Abuse Treatment. This
            includes the President's proposal for $15.8 million to fund a
            joint HHS/HUD homeless program.
      --Increase funding for the Projects for Assistance in Transition from
            Homelessness (PATH) program to $75 million.
      --Provide $3.28 billion for the Community Health Center program, this
            would result in $278 million for the Health Care for the
            Homeless program.
      --Fund the Mental Health Services Block Grant (change name) at $521
            million, a $121 million increase.
      --Fund the Substance Abuse Prevention and Treatment Block Grant at
            $2.008 billion a $289 million increase over fiscal year 2009.
    Background
        While HUD has made significant housing investments, there is a need
    for HHS to increase its role in providing services resources for
    organizations to create permanent supportive housing. A majority of
    chronically homeless individuals live with and face continuing barriers
    to permanent housing due to serious mental illness, substance use
    disorders or chronic health conditions and to retain housing must have
    access services that require HHS expertise.
        We know permanent supportive housing works. Over 80 percent of
    permanent supportive housing residents remain housed after the first
    year. Other studies have shown decreased mortality rates, reduced use
    of alcohol and other drugs, lower HIV viral loads, and improved health
    among chronically homeless people due to placement into supportive
    housing. In addition, work CSH has done targeting frequent users of
    health, jails or prisons illustrates the cost effectiveness of PSH. In
    California, we implemented the Frequent Users of Health Services
    Initiative (FUHSI). Through this study, we found that by placing
    clients into PSH we reduced their emergency room costs by 59 percent,
    reduced their inpatient days by an average of 62 percent and reduced
    average inpatient charges by 69 percent.
        Our project targeting frequent users of jails and prisons has shown
    similar results. The Frequent Users of Services Enhancement (FUSE)
    Initiative is a joint project between the New York City Departments of
    Corrections and Homeless Services with assistance from the Department
    of Health and Mental Hygiene and the New York City Housing Authority.
    By assisting ex-offenders and providing permanent supportive housing to
    those who need it, NYC was able to help clients reduce jail stays by 53
    percent and reduce shelter stays by 92 percent. For the 100 people
    served, the FUSE initiative was able to offset nearly $3,000 in both
    jail and shelter costs per client, not to mention reducing costly
    emergency health services utilization.
        In addition, there are several other subpopulations of those
    experiencing homelessness that would benefit from increased social
    services oriented funding. On a small scale, SAMHSA programs have
    targeted youth, veterans and families to ensure that all people
    experiencing homelessness who could benefit from mental health and
    substance use treatment can receive specialized support. However,
    without increased funding, communities will not be able to fully
    implement the permanent supportive housing model and continue to end
    homelessness in America.
    Detailed Program Descriptions
                SAMHSA Support Services for Permanent Supportive Housing
                        Projects
        CSH 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. The
    Administration obviously recognizes this and included a new initiative
    the Homeless and Services for Homeless Persons Demonstration. This
    joint HUD/HHS partnership is an important first step to integrating
    housing and services resources to ease organizations' ability to access
    Federal funding. It also shows an understanding that housing and
    services is what is needed to end homelessness. This program is
    estimated to cost $15.8 million. CSH asks that this initiative be fully
    funded in the appropriations process and that Congress include
    additional funds to ensure that current grantees can continue their
    work and new grants can be awarded. We look forward to working with
    Congress and the Administration to implement this initiative and ensure
    that it is properly evaluated.
                Projects for Assistance in Transition from Homelessness
                        (PATH)
        CSH 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 (SSI), Medicaid, and welfare programs.
        PATH supported programs served over 135,007 people through outreach
    in fiscal year 2008. Of those for whom a diagnosis was reported,
    approximately 35 percent had schizophrenia and other psychotic
    disorders, and 47 percent had affective disorders such as depression.
    Also, 60 percent had co-occurring substance use disorders.
        One issue that needs consideration, 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.
                Community Health Centers and Health Care for the Homeless
                        (HCH) Programs
        CSH recommends $3.28 billion in the Community Health Center program
    within Health Resource Services Administration. This would result in
    $278 million for the HCH program.
        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.\1\ 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.
    ---------------------------------------------------------------------------
        \1\ Harris, Shirley N, Carol T. Mowbray and Andrea Solarz. Physical
    Health, Mental Health and Substance Abuse Problems of Shelter Users.
    Health and Social Work, Vol. 19, 1994.
    ---------------------------------------------------------------------------
                Mental Health Services Block Grant
        CSH 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
        CSH joins our partners in recommending 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 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 that
    is funded through a grant from the Department of Education, Office of
    Innovation and Improvement.
        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.
        Close Up fulfills its mission with exciting, hands-on programs for
    students and their teachers in Washington. Close Up uses the city as a
    living classroom, giving students unique access to the people,
    processes and places that make up our Nation's capital. 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 for 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 under Section 1504 of the No Child Left Behind Act, has been
    annually funded through a U.S. Department of Education grant for more
    than 35 years. The program provides financial assistance to
    economically disadvantaged high school and middle schools students and
    their teachers. 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 fellowship recipients are selected by their
    schools and must qualify according to the income eligibility guidelines
    established by Close Up.
        Close Up Fellowship Program recipients participate in Close Up
    Washington civic education programs with all other Close Up
    participants. Student fellowship recipients participate in the
    Washington High School Program, the Washington Middle School, and the
    Program for New Americans. There is no special programming for
    Fellowship recipients nor are they identified or singled out in any
    manner. 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 provides a Federal fellowship to a select group of
    teachers who work with economically disadvantaged students on a Close
    Up program. Close Up teachers participate in the Close Up Program for
    Educators, a program which ``trains the trainers''. Teachers take ideas
    and methodologies for teaching and engaging young people in civic
    activities and put them to use in their schools and communities.
        The teacher is the essential link to reaching students of diverse
    backgrounds. Close Up believes that any effort to improve and promote
    civic involvement among young people must begin with inspired and well-
    prepared teachers. It is from this inspired corps of teachers that a
    multiplier effect in civic learning and engagement is produced.
    Teachers who participate in the teacher program leave inspired and
    informed and convey a similar attitude to their students. In a survey
    of teachers who participated on the Close Up Program for Educators in
    spring 2009, 95 percent of the teachers who responded indicated that
    they returned to their schools feeling ``inspired and reinvigorated''
    after completing the Close Up program.
        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 2011 request is based 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
    economic climate it has become even 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 civic education programs also helps to fill a gaping hole
    in the civic education of our Nation's youth. In a recent survey of
    high school teachers, 83 percent reported that emphasis on standardized
    tests has made it difficult to teach practical citizenship skills in
    the classrooms. As the teaching of social studies and civics has given
    way to STEM subjects, programs like Close Up become an even more
    important as a supplement to classroom teaching.
        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 the Close Up Fellowship funding remained flat at 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 greatly supports economic sectors such as
    transportation and hospitality which are suffering in the downturn.
        Senators have the opportunity to meet with Close Up groups from
    their States during Close Up ``Capitol Hill Day''. You see the
    excitement and pride as our students gain confidence to express their
    views on the public policy issues that most directly affect their
    lives. Through their workshops, seminars, and 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 in 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.
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation

        Dystonia is a neurological movement disorder characterized by
    involuntary muscle spasms that cause the body to twist, repetitively
    jerk, and sustain postural deformities. Dystonia can affect movement in
    several different ways; focal dystonias affect specific parts of the
    body, while generalized dystonia affects multiple parts of the body at
    the same time. Some forms of dystonia are genetic, but can also be
    caused by injury or illness. Although dystonia is a chronic and
    progressive disease, it does not impact cognition, intelligence, or
    shorten a person's life span. Conservative estimates indicate that
    between 300,000 and 500,000 individuals suffer from some form of
    dystonia in North America alone. Dystonia does not discriminate,
    affecting all demographic groups. There is no known cure for dystonia
    and treatment options remain limited.
        Although little is known regarding the causes and onset of
    dystonia, two therapies have been developed and proved particularly
    useful to control patients' symptoms. Botulinum toxin (Botox/Myobloc)
    injections and deep brain stimulation have shown varying degrees of
    success alleviating dystonia symptoms. More research is needed to fully
    understand the onset and progression of the disease, in order to better
    treat patients. Until a cure is discovered, the development of
    management therapies remains vital.
    Deep Brain Stimulation (DBS)
        Deep brain stimulation (DBS) is a surgical procedure 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 to deliver electrical stimulation to the areas
    that control movement. While the exact reasons for effectiveness are
    unknown, the electrical stimulation blocks abnormal nerve signals that
    cause debilitating muscle spasms and contractions.
        DBS was approved for use by dystonia patients in 2003 and has since
    drastically improved the lives of many individuals. Results have ranged
    from quickly regaining the ability to walk and speak, to regaining
    complete control over one's body and returning to an independent life
    as an able-bodied person. DBS is currently used to treat severe cases
    of generalized dystonia, but with increased research may also be a
    promising treatment for those suffering from focal dystonias. Surgical
    interventions are a crucial and active area of dystonia research, and
    must be pursued in the development of new 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 biologic, 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,
    providing considerable relief from the patient's symptoms.
        Injections of botulinum toxin should only be performed by a
    physician who is trained to administer this treatment. The physician
    administering treatment may palpate 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 1 to 3 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.
        DMRF supports the recent ``follow-on'' biologics or biosimilars
    provisions included in the Patient Protection and Affordable Care Act.
    This creates a regulatory pathway for biosimilars at the Food and Drug
    Administration (FDA). This will help remove significant cost barriers
    to treatment for dystonia patients and maintain strong patient
    protections, while providing incentive for the development of new
    biologic treatments.
    Dystonia and the National Institutes of Health (NIH)
        Currently, dystonia research at NIH is conducted through the
    National Institutes on Neurological Disorders and Stroke (NINDS), the
    National Institute on Deafness and Other Communication Disorders
    (NIDCD), the National Eye Institute (NEI), and the Office of the
    Director.
    National Institute on Neurological Disorders and Stroke (NINDS)
        The majority of dystonia research at NIH is conducted through
    NINDS. NINDS has utilized a number of funding mechanisms in recent
    years to study the causes and mechanisms of dystonia. These grants
    cover a wide range of research 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 works to
    support NINDS in conducting critical research and advancing
    understating of dystonia.
    National Institute on Deafness and Other Communication Disorders
            (NIDCD)
        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. DMRF
    encourages partnerships between NINDS and NIDCD to further dystonia
    research.
    National Eye Institute (NEI)
        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. While myectomy surgery, botulinum toxin injections, and oral
    medication can help manage some of the symptoms of blepharospasm,
    further study by NEI is needed to develop more predictable treatment
    options.

                Rare Diseases Clinical Research Network (RDCRN)

        The second phase of the RDCRN at NIH provided funding for an
    additional 19 grants aimed at studying the natural history,
    epidemiology, diagnosis, and treatment of rare diseases. This includes
    the Dystonia Coalition, which will facilitate collaboration between
    researchers, patients, and patient advocacy groups to advance the pace
    of clinical research on cervical dystonia, blepharospasm, spasmodic
    dysphonia, craniofacial dystonia, and limb dystonia. Working primarily
    through NINDS and the Office of Rare Disease Research in the Office of
    the Director, the RDCRN holds great hope for advancing understanding
    and treatment of primary focal dystonias.
        After years of near-level funding for NIH, the $10.4 billion
    provided in the American Recovery and Reinvestment Act (ARRA) helped
    reinvigorate biomedical research efforts. However, as those funds come
    to an end, DMRF joins the greater biomedical research community in its
    concern that research funding will ``fall off the cliff.'' In order to
    prevent the loss of research spearheaded under ARRA, continued support
    for initiatives like the Cures Acceleration Network (CAN) included in
    the recent healthcare reform legislation are vital as we push for rapid
    translation of basic science into clinical treatments.
        For fiscal year 2011, DMRF recommends a funding increase of at
    least 12 percent for NIH and its Institutes and Centers.
        For fiscal year 2011, DMRF recommends that the NIH expand dystonia
    research through the National Institute on Neurological Disorders and
    Stroke, the National Institute on Deafness and Other Communication
    Disorders, the National Eye Institute, and the National Institute on
    Child Health and Human Development.
        For fiscal year 2011, DMRF recommends continued partnerships on
    dystonia research between the Office of Rare Disease Research, the Rare
    Diseases Clinical Research Network, and the dystonia patient community.
        For fiscal year 2011, DMRF recommends appropriating $500 million
    for the Cures Acceleration Network, as authorized in the Patient
    Protection and Affordable Care Act.
    The Dystonia Medical Research Foundation (DMRF)
        The Dystonia Medical Research Foundation was founded over 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, we look forward to providing any additional information.
                                     ______

               Prepared Statement of The Elder Justice Coalition

        As your subcommittee considers the fiscal year 2011 Labor, Health
    and Human Services, and Education, and Related Agencies appropriations
    bills, the nonpartisan, 622-member Elder Justice Coalition, urges you
    to provide first year funding for the Elder Justice Act that was
    included in the final healthcare reform bill signed by President Obama.
    By doing so, the nation will have substantially improved our ability to
    better combat elder abuse, neglect and exploitation as well as to
    protect the health of older adults.
        The Elder Justice Act has authorized funding of approximately $777
    million over 4 years. We strongly recommend that an appropriation of
    $195 million for fiscal year 2011 be included in the Labor, Health and
    Human Services, and Education, and Related Agencies appropriations
    bill.
        Its most direct and immediate impact would provide urgently needed
    support for State and local governments for adult protective services
    (APS), the front line of fighting elder abuse. Of the APS agencies in
    30 States responding to a recent national survey of APS programs, 60
    percent reported their budgets had been cut an average of 14 percent,
    while two-thirds reported an average increase of 24 percent in reports
    of abuse. In the Elder Justice Act, $100 million is authorized for APS
    programs for fiscal year 2011.
        Funding for the Elder Justice Act would also provide much needed
    support for long-term care ombudsmen at the State and local levels who
    respond to complaints of abuse and neglect in the Nation's long-term
    care facilities. The number of very complex cases being referred to
    long-term care ombudsman has been steadily increasing. As well, there
    continues to be a very disturbing increase in the frequency and
    severity of regulatory agency citations for egregious violations by
    long-term care providers. Ombudsmen are needed now more than ever in
    nursing homes, board and care facilities, and in assisted living
    communities.
        Elder abuse is a very serious health issue. According to research
    funded by the National Institute of Justice, almost 11 percent of
    people ages 60 and older, or 5.7 million, suffered from some form of
    abuse within the past year alone. Other studies have shown that elder
    victims of abuse, neglect and exploitation have three times the risk of
    dying prematurely.
        The Elder Justice Act promotes the safety and well-being of older
    adults and their families. We urge you to fully fund the Elder Justice
    Act for fiscal year 2011.
                                     ______

             Prepared Statement of the Eldercare Workforce Alliance

        Mr. Chairman and members of the subcommittee: We are writing on
    behalf of the Eldercare Workforce Alliance (EWA),\1\ which is comprised
    of 28 national organizations united to address the immediate and future
    workforce crisis in caring for an aging America. As the Subcommittee
    begins consideration of funding for programs in fiscal year 2011, the
    Alliance asks that you consider $68,723,162 in funding for the
    geriatrics health professions and direct-care worker training programs
    that are authorized under titles VII and VIII of the Public Health
    Service Act as follows:
    ---------------------------------------------------------------------------
        \1\ The positions of the Eldercare Workforce reflect a consensus of
    75 percent of its members. This testimony reflects the consensus of the
    Alliance and does not necessarily represent the position of individual
    Alliance member organizations.
    ---------------------------------------------------------------------------
      --$49,697,421 million for Title VII Geriatrics Health Professions
            Programs;
      --$3,333,333 million for direct care workforce training; and
      --$15,692,408 million for Title VIII Comprehensive Geriatric
            Education Programs.
        These programs are integral to ensuring that America's healthcare
    workforce is prepared to care for our rapidly expanding population of
    older adults.
        The first of the baby boomers will begin to turn 65 in 2011. Within
    20 years, 1 in 5 Americans will be older than 65 and 20 percent of
    those Americans will have one or more chronic conditions. Yet there is
    a growing shortage of clinicians with special training in geriatrics
    and an even greater shortage of the geriatrics faculty needed to train
    the entire workforce.
        In 2008, the Institute of Medicine issued a ground-breaking report,
    Retooling for an Aging America: Building the Health Care Workforce that
    spotlighted these shortages and their impact on care. The report called
    for an expansion of geriatrics faculty development awards to include
    other disciplines of the interdisciplinary team, increased training for
    the direct-care workforce, and other efforts to create a healthcare
    workforce that is competent to care for older adults. The Eldercare
    Workforce Alliance was established to ensure that the IOM
    recommendations are heard.
        The enactment of the Patient Protection and Affordable Care Act
    (PPACA) was a historic moment for healthcare in this country. The Act
    makes important strides toward addressing the severe and growing
    shortages of healthcare providers with the skills and training to meet
    the unique healthcare needs of our Nation's growing aging population.
        The Act includes provisions championed by Senator Kohl (D-WI) and
    Representative Schakowsky (D-IL) from their legislation, the Retooling
    for an Aging America Act (S. 245 and H.R. 468). These provisions
    implement key recommendations of the IOM report to enhance existing and
    establish new geriatrics programs in an effort to build the capacity of
    the healthcare workforce needed to care for older adults.
        While we very much appreciate the funding for the Title VII
    Geriatrics Health Professions programs that President Obama included in
    his fiscal year 2011 budget, the current request does not reflect the
    full amount of funding needed to advance the geriatrics workforce
    priorities established under the PPACA.
        We urge you to fund the geriatrics training programs adequately in
    fiscal year 2011 so that we can immediately begin to realize the
    healthcare workforce goals set forth in health reform. Specifically, we
    request $68,723,162 in funding for the following programs under titles
    VII and VIII of the Public Health Service Act:
    Title VII Geriatrics Health Professions--Appropriations Request:
            $49,697,421
        The Title VII Geriatrics Health Professions Programs, administered
    by the Health Resources and Services Administration (HRSA), are a
    highly effective investment in ensuring that older adults receive high
    quality healthcare now and in the future. These programs--the Geriatric
    Academic Career Awards (GACAs), the Geriatric Education Center (GEC)
    program, and geriatric faculty fellowships--are the only Federal
    programs that: (1) seek to increase the number of faculty with
    geriatrics expertise in a variety of disciplines; and (2) offer
    critically important training to the entire healthcare workforce
    focused on improving the quality of care we offer to America's elders.
    Together, they improve the diversity of the healthcare workforce and
    recruit and retain healthcare professionals in medically underserved
    areas. Furthermore, title VII funding for geriatrics training address
    the crisis created by the severe and growing shortage of geriatrics
    health professionals in the United States.
      --Geriatric Academic Career Awards (GACA).--Under health reform,
            eligibility for these awards has been expanded to include a
            number of new disciplines in addition to physicians.
            Disciplines now eligible for the Award include faculty from
            dentistry, nursing, pharmacy, psychology, social work, and
            other allied disciplines as determined by the Secretary. HRSA
            is moving immediately to implement the expansion of the
            program, which will undoubtedly increase the demand for these
            awards. EWA advocated for this expansion and we now want to
            ensure that there is adequate funding to meet the increased
            demand given the greater number of disciplines that will be
            participating. This program currently funds 77 GAC Awardees and
            we are requesting fiscal year 2011 funding for 250 awards.
      --Geriatric Education Centers (GEC).--Under health reform, Congress
            has approved a supplemental grant award program that will train
            additional faculty through a mini-fellowship program and
            requires that those faculty provide training to family
            caregivers and direct care workers. Our funding request
            includes support for the core work of 48 GECs and for the 24
            GECs that would be funded to undertake this work though the
            supplemental grants program.
      --Geriatric Training Program for Physicians, Dentists, and Behavioral
            and Mental Health Professions.--This program supports training
            additional faculty in medicine, dentistry, and behavioral and
            mental health so that they have the expertise, skills and
            knowledge to teach geriatrics and gerontology to the next
            generation of health professionals in their disciplines. Our
            funding request includes support for 10 institutions to
            continue this important faculty development program.
      --Geriatric Career Incentive Awards Program.--Under health reform,
            Congress has authorized grants to foster greater interest among
            a variety of health professionals in entering the field of
            geriatrics, long-term care, and chronic care management. Our
            funding request includes support for implementation of this new
            program.
    Title VII Direct-Care Worker Training Program--Appropriations Request:
            $3,333,333
        Direct-care workers help older people carry out the basic
    activities of daily living and are critical to ensuring an adequate
    geriatrics workforce. Experts estimate that the United States will need
    to fill one million new direct care positions within this decade.
      --Training Opportunities for Direct Care Workers.--Under health
            reform, Congress has approved a program, administered by HHS,
            that will offer advanced training opportunities for direct care
            workers. These opportunities are critical to the overall
            success of healthcare reform. Our funding request includes
            support for the Department of Labor to establish this unique
            grants-program and support community colleges as they look to
            increase the geriatrics knowledge and expertise of this
            workforce.
    Title VIII Geriatrics Nursing Workforce Development Programs--
            Appropriations Request: $15,692,408
        These programs, administered by the Health Resources and Service
    Administration are the primary source of Federal funding for advanced
    education nursing, workforce diversity, nursing faculty loan programs,
    nurse education, practice and retention, comprehensive geriatric
    education, loan repayment, and scholarship. In 2008, more than 51,657
    nurses and nursing students were supported through these programs.
      --Comprehensive Geriatric Education Program.--This program supports
            additional training for nurses who care for the elderly;
            development and dissemination of curricula relating to
            geriatric care; and training of faculty in geriatrics. It also
            provides continuing education for nurses practicing in
            geriatrics. Our funding request includes ongoing support for
            this critical program.
      --Traineeships for Advanced Practice Nurses.--Under health reform,
            the Comprehensive Geriatric Education Program is being expanded
            to include advanced practice nurses who are pursuing long-term
            care, geropsychiatric nursing or other nursing areas that
            specialize in care of elderly. Our funding request includes
            funds that would offer 200 traineeships to nurses under this
            newly implemented program.
        Without additional funds in these programs, we will fail to ensure
    that America's healthcare workforce will be prepared to care for older
    Americans. We understand that the Committee faces difficult budget
    decisions. However, we strongly believe that by investing in these
    programs, which create geriatrics faculty and offer the training that
    is needed to ensure a competent workforce, we will be delivering better
    care to America's seniors. Healthcare dollars will be saved from better
    healthcare coordination and health outcomes, and the workforce will
    grow as more people are trained, recruited, and retained in the field
    of geriatrics.
        On behalf of all the members of the Eldercare Workforce Alliance,
    we commend you on your past support for geriatric workforce programs
    and ask that you join us in expanding the geriatrics workforce at this
    critical time--for all older Americans deserve quality of care, now and
    in the future.
        Thank you for your consideration.
                                     ______

    Prepared Statement of the Federation of Associations in Behavioral and
                                 Brain Sciences

        Thank you for the opportunity to provide testimony in support of
    NIH-funded research. The Federation of Associations in Behavioral and
    Brain Sciences (FABBS) represents 22 scientific societies with an
    interest in promoting human potential and well-being by advancing the
    sciences of mind, brain, and behavior. Research covering the spectrum
    from genes and molecules, to the brain and mind, and to behavior,
    social relationships, culture and the environment are necessary to
    provide a full understanding of health and disease.
        NIH is supporting research that will lead to ground-breaking
    discoveries that will improve health and save lives. An essential part
    of the overall research portfolio is research on the mind, brain, and
    behavior. Basic and applied research that examines how the mind
    functions, its relation to behavior and society, and its underlying
    biology are critically important in understanding, preventing, and
    treating disease.
        Important transformations are occurring in science. Scientists
    often work at different levels of analysis by examining, for example,
    the impact of genes on health or alternatively, the influence of
    culture on health. Both are necessary to address central questions
    about health and illness. Increasingly, however, scientists are also
    exploring the margins and bringing to bear multiple disciplines, tools,
    technologies, and approaches to inform their work. All are necessary if
    we are to truly understand the human condition and, in turn, enhance
    human health, potential, and productivity.
    The Role of Emotions, Cognitions, and Environment in Health and Illness
        NIH is supporting the best research both within and across
    disciplines to better understand the contributors to illness and
    disease. In one program of research, investigators are attempting to
    understand the mechanisms--neural, hormonal, cellular, genetic--by
    which loneliness gets under the skin to affect health, and importantly,
    how the mind can modulate these health outcomes. Humans are social
    beings and spend about 80 percent of their time, on average, with other
    people. Much research has shown that people who are socially isolated,
    or perceive that they are socially isolated, have poorer health
    outcomes. Specifically, loneliness has been associated with increased
    duration and extent of illnesses ranging from the common cold to
    depression to heart disease. The affected factors contributing to these
    effects include diminished immune system responses, elevated blood
    pressure, and even changes in gene expression. This new field of social
    neuroscience is illuminating how the social environment affects
    cognition, emotion, personality processes, brain, biology, and health.
        Research in this area suggests that the risks associated with
    developing heart disease that are posed by social isolation may be as
    high as those posed by high cholesterol, high blood pressure, and even
    smoking. Research has also shown that perceptions of being alone may be
    more harmful to health than actually being alone. By understanding the
    mechanisms by which social networks, mental processes, and biology are
    linked, efforts can be made to translate this work more readily into
    clinical contexts.
        NIH is also supporting highly innovative research to better
    understand emotions, since emotional states are central to mental and
    physical health. With funding from the NIH Director's Pioneer Award,
    one investigator is examining the complex mental and physical processes
    in emotions. What is the physiological state giving rise to an emotion,
    and how does the mind make meaning of the physical state? How does the
    mind control emotions, and what role does context play in emotions?
    Simply put, emotions may not be simple reflexes that turn on parts of
    the brain, but are likely much more complex. Emotional disturbances
    exact a huge toll on patients, and this research has the potential to
    transform our understanding of a broad area of science.
        Complex medical problems require approaches that draw upon a range
    of scientific areas to address health challenges. These research
    programs illustrate some of the exciting new work in the mind, brain,
    and behavioral sciences funded by NIH.
    The Importance of Fundamental Research at NIH
        NIH investments in basic research are a critical part of the
    overall research portfolio at NIH. A basic understanding of how cells
    and genes function is a necessary building block. The same is true for
    fundamental research in the mind, brain, behavior sciences. As Dr.
    Collins has noted, NIH's mission is ``science in pursuit of fundamental
    knowledge about the nature and behavior of living systems and the
    application of that knowledge to extend healthy life and to reduce the
    burdens of illness and disability.''
        We commend NIH for its leadership in developing research
    initiatives that will build a base of knowledge to inform many public
    health challenges facing this country--from cancer, heart disease, and
    HIV to diabetes and childhood obesity. One such initiative, called
    OPPNET for Opportunity Network, was launched in November 2009 by NIH
    Director Francis Collins M.D., Ph.D. The new trans-NIH initiative will
    provide funding for emerging areas in the behavioral and social
    sciences, similar to the research described above. OPPNET will build
    upon existing NIH investments to create a body of knowledge about the
    nature of behavior, the underlying mental and physical processes, and
    how social factors influence it. As with basic research on genes and
    molecules, this research is a necessary building block upon which many
    other advances in science will be possible.
        Initiating health-promoting behaviors and maintaining positive
    changes remain a central question in health research. Behavior has a
    pervasive impact on health, and despite advances in the science,
    significant and sustained behavior change remains elusive. Given its
    importance, NIH is investing in a new cross-NIH and cross-disciplinary
    research agenda on the basic science of behavior change. The goal is to
    ``radically move this science forward.'' Key themes identified by
    scientists for a new research agenda include integrating the science at
    multiple levels (i.e., brain, person, and environment) such that
    behavior changes can be seen at a population level. Also, there is a
    need to better understand the basic mechanisms of behavior change,
    examine key opportunities for changing behavior at various points in
    the lifespan, and to target multiple behaviors at once since unhealthy
    behaviors can have common underlying processes. The Science of Behavior
    Change is one of seven new NIH Common Fund initiatives, one in which
    NIH is pushing science to cross traditional disciplinary and topical
    boundaries. These basic science initiatives are supported by multiple
    Institutes across NIH.
        Using its modest budget, the Office of Behavioral and Social
    Sciences Research (OBSSR), created by Congress in 1993, continues to
    play a key role in coordinating and facilitating initiatives across the
    Institutes. In addition, OBSSR identifies new and promising
    opportunities for the behavioral and social sciences to help advance
    NIH's mission. Projects underway or in the pipeline include improving
    our knowledge of the interplay among behavior, environmental factors
    (particularly social environment), and genomic/epigenetic factors in
    health illness; applying complex systems modeling to understanding and
    ameliorating health disparities; promoting initiatives in health
    literacy and community-based participatory research in medically
    underserved populations; and identifying prevention strategies for
    healthcare that are both grounded in science and cost-effective.
    Translating Basic Behavioral and Social Science Discoveries
        NIH's investments in basic research will lead to discoveries that
    can be translated for use in clinical settings. Indeed, NIH is
    increasingly turning its attention to this process. As NIH Director,
    Dr. Collins has made this 1 of his 5 priorities. Likewise, behavioral
    and social scientists at NIH are examining the opportunities and
    challenges for translating promising findings from these sciences for
    use in community and clinical care settings. For example, efforts to
    translate basic behavioral and social science research findings into
    behavioral interventions to reduce obesity will inform a critical
    public health challenge facing this country. Translational research
    will improve our ability to convert basic science discoveries into
    meaningful community and clinical interventions.
    Building Research Capacity in All Sciences
        The sciences of mind, brain, and behavior are critical to the
    health and well-being of our Nation's citizens and, in turn, the
    Nation's prosperity. The development and progression of many illnesses
    and health problems such as heart disease, diabetes, and obesity depend
    on behavior. In addition, advancing knowledge in the behavioral and
    social sciences is increasingly requiring technical expertise. For
    example, to understand the workings of the mind, scientists must be
    able to utilize fMRI, MEG, and EEG tools. Investing in research and
    training in the behavioral and social sciences, as well as research and
    training that involve behavioral and social scientists and cross
    disciplinary boundaries, will address current needs and help prepare
    the next generation of researchers. The Nation must build capacity in
    all sciences and at all educational levels to address health needs and
    remain competitive.
    Fiscal Year 2011 Funding Request for NIH
        This is an incredible time for science. Investments by Congress in
    2009 and a commitment by the administration to science are allowing
    mid-career and senior scientists to remain at work on complex health
    problems facing our society, while also attracting a new generation of
    scientists to become engaged and excited about careers in science. In
    addition, new discoveries within scientific disciplines and across
    disciplinary boundaries, are keeping the U.S. competitive. These
    investments are making a difference back home, both in dollars that
    support research positions at local universities and in the innovations
    that improve health throughout our communities.
        Investments in science will continue to spur economic growth now
    and well into the future. We urge this subcommittee to support $35
    billion for the National Institutes of Health in the fiscal year 2011
    appropriation.
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology

        On behalf of the Federation of American Societies for Experimental
    Biology (FASEB), I respectfully request an appropriation of $37 billion
    for the National Institutes of Health (NIH) in fiscal year 2011.
    Sustained and predictable public support for biomedical research is
    needed to accelerate the pace of discovery, improve the health of our
    Nation's citizens, and contribute to the economic revitalization of our
    country.
        As a Federation of 23 scientific societies, FASEB represents more
    than 90,000 life scientists and engineers, making us the largest
    coalition of biomedical research associations in the United States.
    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 scientists and
    engineers to improve--through their research--the health, well-being,
    and productivity of all people.
        Due to the prior Federal investment in NIH, researchers have made
    critical advances that have saved and improved the lives of millions of
    Americans and provided doctors with cutting-edge tools to prevent and
    treat costly and devastating diseases including:
      --Type 2 Diabetes.--In the United States, about 11 percent of
            adults--24 million people--have diabetes, and up to 95 percent
            of them have type 2 diabetes. An additional 57 million
            overweight adults have glucose levels that are higher than
            normal but not yet in the diabetic range, a condition that
            substantially raises the risk of a heart attack or stroke and
            of developing type 2 diabetes in the next 10 years. Researchers
            have recently demonstrated, based on a decade of data
            collection, that intensive lifestyle changes aimed at modest
            weight loss reduced the rate of developing type 2 diabetes by
            34 percent in people at high risk for the disease. Intensive
            lifestyle changes consisted of lowering fat and calories in the
            diet and increasing regular physical activity to 150 minutes
            per week. Participants received training in diet, exercise
            (most chose walking), and behavior modification skills.
      --Melanoma.--Drawing on the power of DNA sequencing, NIH researchers
            identified a new group of genetic mutations involved in the
            deadliest form of skin cancer, melanoma. This discovery is
            particularly encouraging because some of the mutations, which
            were found in nearly one-fifth of melanoma cases, reside in a
            gene already targeted by a drug approved for certain types of
            breast cancer. In the United States and many other nations,
            melanoma is becoming increasingly more common. A major cause of
            melanoma is thought to be sun exposure; the ultraviolet
            radiation in sunlight can damage DNA and lead to cancer-causing
            genetic changes within skin cells.
      --Seasonal and Pandemic Flu.--Scientists have identified a small
            family of lab-made proteins that neutralize a broad range of
            influenza A viruses, including the H1N1 flu viruses, the 1918
            pandemic influenza virus, and H5N1 avian virus. These human
            monoclonal antibodies, identical to infection-fighting proteins
            derived from the same cell lineage, also were found to protect
            mice from illness caused by H5N1 and other influenza A viruses.
            Because large quantities of monoclonal antibodies can be made
            relatively quickly, these influenza-specific monoclonal
            antibodies potentially could be used in combination with
            antiviral drugs to prevent or treat the flu during an influenza
            outbreak or pandemic.
      --Stroke.--Scientists have identified a previously unknown connection
            between two genetic variants and an increased risk of stroke,
            providing strong evidence for the existence of specific genes
            that help explain the genetic component of stroke.
      --Heart Disease.--There has been a 63 percent reduction in deaths
            from heart disease, and more than 1 million lives are saved
            each year by therapies developed to prevent heart attack and
            stroke.
      --Cancer.--Since 2002, the number of deaths from cancer has decreased
            steadily. In the past 30 years, survival rates for childhood
            cancers have increased from less than 50 percent to more than
            80 percent.
      --HIV/AIDS.--This disease has been transformed from an acute, fatal
            illness to a chronic condition; the prophylactic use of anti-
            virals prevented almost 350,000 deaths worldwide in 2005. In
            the United States, deaths from AIDS dropped nearly 70 percent
            between 1995 and 2000. Life expectancy for those infected with
            HIV has increased by 10 years.
        The completion of the Human Genome Project and the resulting
    reductions in genome sequencing costs are another example of how the
    prior investment in research has both dramatically increased the pace
    of discovery and harnessed the power of technology. Genome sequencing
    brings us to the threshold of personalized medicine, where knowledge of
    our own individual genetic makeup can be used to target cures and
    identify the most effective therapies for individuals. Researchers are
    at the beginning of a whole new era of pharmacogenomics that will
    identify methods to tailor treatments and scientifically match
    therapies to individual circumstances in ways that were inconceivable a
    few years ago.
        Knowledge of an individual's genetic make-up has already been
    effective in determining which drugs work best with certain cases of
    AIDS, breast cancer, acute lymphoblastic leukemia, and colon cancer.
    The number of new research proposals is expected to expand dramatically
    as researchers exploit this exciting line of inquiry, yet continued
    progress toward that goal depends on sustained and predictable funding
    support for the NIH.
    Sustainable Budget Growth Will Maximize the Return on Investment
        Additional funding is needed to fully develop the knowledge we have
    gathered to date and to apply that knowledge in clinical settings. The
    research engine needs a predictable, sustained investment in science to
    maximize our return on investment. The discovery process--while
    producing 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 are disruptive to
    training, careers, long-range projects, and ultimately to scientific
    progress. 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, continuous growth that will enable us to complete President
    Obama's vision of doubling our investment in basic research.
        The most painful consequence of failing to continue the robust
    investment in research will be the delay in relief to those suffering
    from the burdens of disease. Long-term plans for Federal investment in
    science facilitate coordination and planning, encourage investments by
    the private sector, attract new talent, reduce the startup costs of
    projects, and eliminate the possibility of waste that could result from
    abrupt termination of valuable scientific investigations.
    Prosperity and Quality of Life Are Shaped By Investments in Science
        As a Nation, we currently find ourselves confronting a number of
    unprecedented social and economic challenges, and once again our
    leaders have turned to research in the quest for solutions to these
    vexing problems. Funds from the American Recovery and Reinvestment Act
    (ARRA) have inspired the creative energies of research teams across the
    Nation. These new resources, coming after many years during which our
    capacity for research was eroded by flat budgets, are a lifeline for
    new ideas, research personnel, and progress.
        ARRA funding was only appropriated for a 2-year period, and we face
    a major shortfall when these funds have been spent. Returning to pre-
    ARRA funding levels presents a frightening prospect for those whose
    hopes for a brighter future rest with medical research. It will also be
    a setback for the scientists who have contributed so much of their time
    and talent to this quest. It is critical that we invest now to sustain
    the excitement in research, maximize the return on our prior
    investments, and continue the innovative pipeline of medical and
    technological advancements that Federal science agencies have always
    fostered.
        Despite the fragile economy, now is not the time to pull back from
    our historic commitment to investigation and discovery. Our leadership
    in science and engineering has made us the envy of the world. However,
    we must nurture our research investment to benefit from the knowledge
    that we have gained and ensure that continued progress is not
    curtailed. President Obama has recognized the importance of continuing
    support for the NIH in his proposed budget for fiscal year 2011.
        A half-century of public investment in NIH has dramatically
    advanced the health and improved the lives of Americans and of people
    around the globe. Unfortunately, millions of Americans and their
    families still suffer from the ravages of disease and cannot wait for
    new treatments, therapies, and prevention strategies. Sustained and
    predictable public support for biomedical research is needed now more
    than ever. We recognize that this subcommittee has the especially
    difficult task of providing funding for a wide range of critical human
    service programs and thank you for your prior support of the research
    enterprise. Nonetheless, additional resources are needed to pursue the
    unprecedented level of scientific opportunities available today and
    uphold the Nation's role as a leader in medical research. Therefore,
    FASEB recommends an appropriation of $37 billion for NIH fiscal year
    2011.
                                     ______

                   Prepared Statement of the Friends of NIAAA

        Mr. Chairman and members of the subcommittee: The Friends of the
    National Institute on Alcohol Abuse and Alcoholism, a coalition of
    scientific and professional societies, patient groups, and other
    organizations committed to preventing and treating alcohol use
    disorders as well as understanding the causes and public health
    consequences of alcoholism and alcohol use disorders, is pleased to
    provide testimony in support of the NIAAA's extraordinary work. The
    coalition does not receive any Federal funds.
        The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is
    the lead agency for U.S. research on alcohol abuse, alcoholism, and
    other health and developmental effects of alcohol use. Its mission is
    to support research, and then translate and disseminate research
    findings to reduce alcohol-related problems. NIAAA funds 90 percent of
    all alcohol research in the United States. From fetal alcohol syndrome
    to alcohol dependence, and from liver cirrhosis to alcohol poisoning,
    the consequences of alcohol misuse are widespread and costly, and
    affect individuals of every age, ethnic background, and socioeconomic
    status. Drinking too early, too fast, too much, and/or too often can
    lead to acute and chronic consequences for the drinker as well as
    outcomes affecting the health and well-being of others and society-at-
    large.
        Approximately 18 million Americans meet the criteria for a
    diagnosis of alcohol dependence (alcoholism) or alcohol use disorders
    (AUD), and 40 percent of Americans have direct family experience with
    alcohol use disorders or dependence. Annually, 80,000 deaths are
    attributable to alcohol, as are approximately one-third of all fatal
    car crashes, one-half of all homicides, one-third of all suicides, and
    one-third of all hospital admissions. In fact, excessive alcohol
    consumption is the third leading preventable cause of death in the
    United States. AUDs cost the Nation $235 billion annually, nearly 80
    percent more than the costs related to all other addictive drugs.
        Because of the critical importance of alcohol research for the
    health and economy of our Nation, we write to you today to request your
    support for a modest 2.7 percent increase for NIAAA in the fiscal 2011
    Labor, Health and Human Services, and Education, and Related Agencies
    appropriations bill. That would bring total funding for NIAAA in fiscal
    year 2011 to $474,649,000. This work deserves continuing, strong
    support from Congress. The following is a list of key new NIAAA
    initiatives that could be pursued with additional investment, and a
    short summary of significant NIAAA accomplishments and successes.
        NIAAA initiatives for fiscal year 2011:
      --NIAAA will continue to support research on the mechanisms by which
            alcohol causes damage to, as well as pharmacologic agents that
            lessen alcohol's adverse effects on, the developing embryo and
            fetus. Resources will also be directed towards the development
            of biomarkers, which could be used to detect alcohol exposure
            in pregnant women.
      --New initiatives in fiscal year 2011 will support several broad
            National Institutes of Health themes, including applying
            genomics and other high throughput technologies to understand
            fundamental biology, and to uncover the causes of specific
            diseases, translating science into new and better treatments
            and putting science to work for the benefit of healthcare
            reform.
      --NIAAA will support the continuing development of a screening guide
            for use with children and adolescents to assess for risk of
            alcohol use and alcohol use disorders. In addition, NIAAA is
            planning a new research initiative on pharmacotherapy for
            adolescents and young adults with severe alcohol use disorders
            and major co morbidities, as well as behavioral interventions
            that target young individuals along the continuum of alcohol-
            related behaviors.
      --In fiscal year 2011, NIAAA will continue to promote and disseminate
            its Web-based booklet Rethinking Drinking. NIAAA is planning a
            new initiative exploring the effects of community interventions
            on alcohol related outcomes in young adults. Research has
            demonstrated that comprehensive community interventions that
            typically involve multiple levels of city government,
            environmental policy change and community involvement, among
            other factors, may reduce alcohol-related problems among
            adolescents and young adults, including college students.
      --NIAAA is planning a new initiative on developing effective
            pharmacological and behavioral treatments for individuals who
            have alcohol use disorders and co-existing other drug,
            psychiatric, and/or physical disorders. NIAAA will also support
            studies aimed at risk reduction, early identification and
            diagnosis of harmful alcohol use and personalized treatment.
            Additional funds will be committed for research on the
            underlying mechanisms of alcohol-induced liver injury and the
            identification of biomarkers of alcohol-induced tissue injury.
            These studies are expected to reveal new therapeutic targets,
            inform strategies for preventing tissue injury, facilitate
            early diagnosis, and improve the prognosis for alcohol-related
            liver disease.

    A Partial List of Important NIAAA Innovations
                Advancing the Understanding of the Mechanisms and
                        Consequences of Prenatal Alcohol Exposure
        The Friends of NIAAA commends the Institute for its research to
    enhance our ability for early identification of and interventions with
    prenatal alcohol affected children; exploring nutritional and
    pharmacological agents that could lessen alcohol's adverse effects on
    the developing embryo/fetus; and research on how alcohol disrupts
    normal embryonic and fetal development. Research has shown that the
    severity of alcohol-related effects on the developing fetus is affected
    by the timing and level of maternal alcohol consumption, maternal
    nutritional status, and maternal hormones. One of the key challenges
    facing clinicians is the ability to recognize women who are drinking in
    pregnancy and the infant who has been exposed prenatally to alcohol
    during pregnancy. Recently there have been advances in methodologies
    for the measurement of nonoxidative metabolites of alcohol providing
    new opportunities for monitoring alcohol exposure.
    Understanding the Effects of Alcohol use on the Developing Body and
            Brain, and the Interplay of Development, Genes and Environment
            on Adolescent Alcohol use
        As adolescence (ages 0-17) is the time of life during which
    drinking, binge drinking (drinking five or more drinks on one
    occasion), and heavy drinking (binge drinking five or more times in the
    past 30 days) all ramp up dramatically, the Friends of NIAAA is pleased
    that the Institute is vigorously focused on these concerns. Given that
    alcohol use is pervasive among adolescents and the association between
    early initiation and future alcohol problems, NIAAA is developing
    empirically based guidelines and recommendations for screening children
    and adolescents to identify risk for alcohol use especially for younger
    children; alcohol use, and alcohol use disorders. NIAAA is also
    supporting studies to integrate intervention for underage alcohol use
    into primary healthcare. Research has shown that during adolescence,
    the brain undergoes significant growth and remodeling. This finding,
    coupled with the results of multiple studies showing a strong
    association between early initiation of alcohol use and future alcohol
    dependence, raises concerns about alcohol's effects on the developing
    adolescent brain.
        Specifically, the issues are whether persistent changes in neural
    and behavioral function result from adolescent alcohol use, and whether
    processes that confer adaptability of the adolescent brain to its
    environment also make it more vulnerable to alcohol-induced changes in
    structure and/or function, especially in terms of setting it up for
    future dependence. Complementing NIAAA's ongoing pilot studies with
    humans to determine if alcohol can disrupt, co-opt and/or alter normal
    developmental processes in the brain, NIAAA is also planning an
    initiative to study persistent alcohol-induced changes in the brain in
    animal models.
    Pioneering Risk Assessment, Universal and Selective Prevention, and
            Early Intervention and Treatment for Young Adults
        Given the pervasiveness of high-risk drinking and early alcohol
    dependence occurring among young adults, efforts to alter drinking
    trajectories at this stage have life-changing potential and can
    significantly reduce the burden of illness resulting from alcohol-
    related problems. Recent research has demonstrated that college-aged
    individuals respond well to Web-based screening and self-change
    programs, resulting in reductions in adverse alcohol-related
    consequences. Making alcohol screening and brief intervention a routine
    procedure in primary care and other settings is a high-priority of
    NIAAA.
    Exploring Pharmacologic Interventions for Alcohol-use Disorders
        In addition to its role in alcohol dependence, excessive alcohol
    consumption can have toxic effects on virtually every organ system in
    the body resulting in liver and heart disease, pancreatitis, fetal
    abnormalities, brain damage, and an increased risk for esophageal and
    liver cancer. Liver disease in particular claims 37,000 lives annually,
    about 40 percent of which are due to excessive alcohol use. Currently
    the only treatment for liver cirrhosis--the end stage of alcoholic
    liver disease--is liver transplantation which is impacted by limited
    availability of matching organs, high medical costs, and increased risk
    for future health complications. Intervening early in the disease
    process continues to be an important priority of NIAAA, and research is
    moving us closer to developing medications that can slow or even
    reverse disease progression and/or mitigate health consequences. For
    example, preliminary research has shown that administration of the
    dietary supplement S-adenosylmethionine (SAMe) may reverse disease
    symptoms in individuals with early stage liver disease and pre-empt
    cirrhosis. A phase 2 clinical trial testing the effects of this
    compound is currently underway. NIAAA and NIDDK are co-funding a
    project focused on developing small molecules to reverse alcoholic
    liver fibrosis, as well as liver damage resulting from obesity and
    metabolic syndromes. Animal studies evaluating prenatal and early
    postnatal supplementation with the nutrient choline, a molecule
    important to the structure and function of cell membranes, have shown
    reduced severity of certain behavioral and physical effects of prenatal
    alcohol exposure. For alcohol dependence, NIAAA is moving medications
    that promote abstinence and/or reduction in heavy drinking through the
    medications development pipeline via its early phase 2 clinical trials
    program. These include trials for quetiapine, a mood stabilizing drug,
    completed in late fiscal year 2009 and for levetiracetam, an
    antiepileptic medication, initiated in late fiscal year 2009.
    Improving the Identification of Mechanisms by Which Alcohol and its
            Metabolites Cause Tissue and Organ Pathologies, and the
            Development of Treatment Strategies for Alcohol Dependence
            Tailored to Specific Populations and for Individuals With Co-
            Existing Psychiatric and Medical Disorders
        Over the past four decades, numerous scientific advances have been
    made in identifying the pathologic effects of alcohol and its metabolic
    products on the brain, liver, heart, pancreas, and immune and endocrine
    systems. Recently, NIAAA has taken a systems biology approach,
    investigating how perturbation of one organ system by alcohol
    influences other organ systems, leading to a cascade of effects
    throughout the body. Alcohol consumption sets in motion a number of
    signaling processes which operate directly and indirectly on multiple
    systems in the body. For example, one mechanism by which alcohol
    negatively impacts the liver and brain is through signaling molecules
    released from the gut. The gut normally contains bacteria whose outer
    membranes consist primarily of large amounts of molecules known as
    lipopolyscaccharides (LPS). Alcohol increases gut ``leakiness''
    allowing LPS to travel throughout the body, resulting in inflammation
    in both the brain and liver. Liver inflammation then triggers the
    release of cytokines, signaling molecules that promote further
    inflammation in the brain. Gut ``leakiness'' may also be the mechanism
    by which alcohol disrupts immune function. Another target of alcohol
    may be the hypothalamic pituitary adrenal axis (HPA axis), a major part
    of the neuroendocrine system that regulates reactions to stress and
    many body processes, including digestion, the immune system, mood and
    emotions, sexuality, and energy storage and expenditure. Considering
    the human body as a complex network in which perturbations of one organ
    system alters interactions with other organ systems thereby affecting
    the functions of each, will enable the development of treatments that
    address the source(s) of alcohol-induced tissue and organ damage.
        The Friends of NIAAA commends the National Institute on Alcohol
    Abuse and Alcoholism for making significant progress in these and many
    other vital areas of research that are essential to the health and
    well-being our Nation.
        Thank you, Mr. Chairman, and the subcommittee, for your support for
    the National Institute on Alcohol Abuse and Alcoholism.
                                     ______

                   Prepared Statement of the Friends of NICHD

        The Friends of the National Institute of Child Health and Human
    Development (NICHD) is a coalition of more than 100 organizations,
    representing scientists, physicians, healthcare providers, patients,
    and parents, concerned with the health and welfare of women, children,
    families, and people with disabilities. We are pleased to submit
    testimony to support the extraordinary work of the Eunice Kennedy
    Shriver National Institute of Child Health and Human Development.
        We would like to thank Chairman Harkin, Ranking Member Cochran, and
    the Congress for its continued support of the National Institutes of
    Health (NIH) and interest in building on the investments made in
    predictable and sustained, long-term growth in NIH funding in the
    fiscal year 2011 budget and beyond. To ensure that progress in basic,
    translational and clinical research is sustained, the Coalition joins
    the Ad Hoc Group for Medical Research in supporting a fiscal year 2011
    appropriation of at least $35 billion, an increase of $2.6 billion for
    NIH.
        The Coalition has a particular interest in the important research
    conducted and supported by the NICHD. Since its establishment in 1963,
    the NICHD has made great strides in meeting the objectives of its broad
    biomedical and behavioral research mission. The NICHD mission and
    portfolio includes a focus on women's health and human development,
    including research on child development, before and after birth;
    maternal, child, and family health; learning and language development;
    reproductive biology and population issues; and medical rehabilitation.
        Although the NICHD has made significant contributions to the well-
    being of children, women, and families, much remains to be done. With
    sufficient resources, the NICHD could build upon the promising
    initiatives described in this testimony and produce new insights into
    human development and solutions to health and developmental problems
    for the world and for the Nation--including the families living in your
    districts. For fiscal year 2011, the Friends of NICHD support an
    appropriation of at least $1.495 billion for NICHD.
    New Discoveries
        Adding to its strong record of progress over the past 45 years,
    recent advances by the NICHD have contributed to the health and well-
    being of our Nation and world. Several highlights are:
        Tracking Brain and Behavioral Development.--The NICHD is one of the
    leading Institutes in the NIH Magnetic Resonance Imaging (MRI) Study of
    Normal Brain Development. The study tracks brain and behavioral
    development in 500 healthy children from diverse backgrounds birth to
    age 18. The latest findings show that children appear to have reached
    adult levels of performance on basic cognitive and motor skills by age
    11 or 12. Long-term, the goal is to link these behavioral data to MRI
    scans of the children's brains. Together, the two data sets will allow
    researchers to view how the brain grows and reorganizes itself, and to
    explore the structural changes. The database will also serve as a
    reference to better understand what goes wrong in children with genetic
    disorders, language and learning difficulties, prenatal exposure to
    alcohol or drugs or other brain injury.
        Preterm Birth Risk Factors.--Researchers funded by the NICHD
    identified DNA variants in mothers and fetuses that appear to increase
    the risk for preterm labor and delivery. The current findings add to
    the evidence that individual genetic variation may account for why
    preterm labor occurs in some pregnancies and not in others. The
    findings may one day lead to new strategies to identify those at risk
    for preterm birth, and to ways to reduce the occurrence of preterm
    birth among those at risk.
        Treating Mild Gestational Diabetes Reduces Birth Complications.--
    NICHD funded researchers found the first conclusive evidence that
    treating pregnant women who have even the mildest form of gestational
    diabetes can reduce the risk of common birth complications among
    infants, as well as blood pressure disorders among mothers.
    Specifically, women treated for mild gestational diabetes had smaller,
    leaner babies less likely to be overweight and less likely to
    experience shoulder dystocia, an emergency condition in which the
    baby's shoulder becomes lodged inside the mother's body during birth.
    Treated mothers were also less likely to undergo cesarean delivery, to
    develop high blood pressure during pregnancy, or to develop pre-
    eclampsia, a life-threatening complication of pregnancy that can lead
    to maternal seizures and death.
    Future Research Opportunities
        Although the studies mentioned above have unquestionably made
    significant contributions to the well-being of our children and
    families, there is still much to discover about ways to improve health,
    learning, and quality of life. Progress in the following research areas
    can only be achieved with adequate Federal investments.
        Severe, Early Adverse Pregnancy Outcomes.--Women with severe, early
    adverse pregnancy outcome, such as multiple losses, demises, and severe
    preeclampsia, are at increased risk for long-term chronic health
    problems, including hypertension, stroke, diabetes, and obesity.
    Studies have shown that women who have had preeclampsia are more likely
    to develop chronic hypertension, to die from cardiovascular disease and
    to require cardiac surgery later in life. In addition, approximately 50
    percent of women with gestational diabetes will develop diabetes later
    in life. Pregnancy can be considered as a window to future health and
    the immediate postpregnancy period provides a unique opportunity for
    prevention of chronic diseases later in life. Studies to identify women
    at risk for long-term morbidity, and to develop strategies to prevent
    long-term adverse outcomes in these women are urgently needed.
        Preterm Birth.--Preterm birth is a serious and growing public
    health problem that affects more than 500,000 babies each year. It is
    the leading cause of neonatal death and about half of all premature
    births have no known cause. A key strategy recommended by the Institute
    of Medicine and experts convened for the Surgeon General's Conference
    on the Prevention of Preterm Birth is to create integrated
    transdisciplinary research centers to build the knowledge base needed
    for development of effective interventions to prevent prematurity.
    These new centers would serve as a national resource for investigators
    to design new research approaches and strategies to address the serious
    and growing problem of preterm birth.
        National Children's Study.--The National Children's Study is the
    largest and most comprehensive study of children's health and
    development ever planned in the United States. Currently, the
    ``vanguard centers'' are recruiting pregnant women and more than 150
    children have been born into the study. When fully implemented, this
    study will follow a representative sample of 100,000 children from
    across the United States from before birth until age 21. The data
    generated will inform the work of scientists in universities and
    research organizations, helping them identify precursors to disease and
    to develop new strategies for prevention and treatment. Identifying the
    root causes of many childhood diseases and conditions, including
    preterm birth, asthma, obesity, heart disease, injury and diabetes,
    will reduce healthcare costs and improve the health of children. The
    Friends of NICHD thank the subcommittee for funding the NCS through the
    NIH Office of the Director in fiscal year 2010, and urge the
    subcommittee to provide $194.4 million for the study in fiscal year
    2011.
        Newborn Screening Translational Research Network.--The network is
    designed to improve newborn screening, the care of patients with
    disorders identified through screening, and deepen understanding of
    conditions for which screening should be made available. By
    contributing to our understanding of patients with genetic diseases,
    this network will accelerate research in diseases related to newborn
    screening and greatly improve the process by which public health
    decisions are made about the expansion of newborn screening.
        Unraveling Genetic Basis of Autism.--NICHD is capitalizing on
    advances in genetics research by participating in the Autism Genome
    Project (AGP), a public-private collaboration involving more than 120
    scientists and 50 institutions in 19 countries. The first study to
    emerge from AGP implicated components of the brain's glutamate chemical
    messenger system and a previously overlooked site on chromosome 11.
    Based on 1,168 families with at least 2 affected members, the genome
    scan also adds to evidence that tiny, rare variations in genes may
    heighten risk for autism spectrum disorders. The spectrum of disorders
    collectively known as autism affects as many as one in 150 Americans
    resulting in impaired thinking processes, emotional and social
    abilities, and motor control. So far, the only known cause of autism
    for which there is a verifiable blood test is Fragile X; further
    research on this disorder would provide understanding of the function
    of this gene (FMR1) as well as others that cause autism. With NIH
    support, the AGP is pursuing studies to identify specific genes and
    gene variants that contribute to vulnerability to autism. These include
    explorations of interactions of genes with other genes and with
    environmental factors, and laboratory research aimed at understanding
    how candidate susceptibility genes might work in the brain to produce
    the disorders.
        Education and School Readiness Research.--NICHD continues to build
    its portfolio of research on how children acquire the emotional, social
    and academic skills necessary to succeed in school and beyond; however
    more work is needed in four particular areas: (1) Neurological
    processing disorders--how they impact learning and literacy,
    particularly in reading comprehension for grades 4-8, so that early
    intervention may improve learning and academic outcomes for young
    adults; (2) learning delays and language development--how to
    distinguish if they are caused by language barriers versus possible
    learning disabilities in school-age children; (3) math disabilities--
    where they reside in the brain, how they impact learning over time and
    what we can do to remediate and intervene with those who have them; and
    (4) school readiness--how to develop better measures of the social and
    emotional bases which will inform our early education programs. The
    combination of study in these four areas will help inform the Nation's
    education and innovation agenda to support and grow a competitive
    workforce.
        Family Research.--As the family is the primary context for child
    development, the NICHD has played a significant role in examining the
    dramatic changes in family structure in the United States over the last
    40 years. Scientists are currently focused on developing new study
    designs to better understand the family processes that transcend the
    traditional home environment, including the role of absent fathers, the
    contributions of grandparents and others outside the immediate family.
    Recognizing that so many parents are also in the workforce, NICHD is
    moving forward on its Work, Family, Health and Well-Being Initiative.
    The long-range goals of the initiative are to identify workplace
    interventions that can improve health by improving the ability of the
    worker to successfully meet both work and family demands.
        Intellectual and Developmental Disabilities.--Ongoing support of
    the research in mental retardation and developmental disabilities being
    undertaken at the Eunice Kennedy Shriver Intellectual and Developmental
    Disabilities Research Centers (IDDRC) is essential. Many disorders are
    being studied by the IDDRC such as Down syndrome, Fragile X syndrome,
    Rett syndrome, and autism. Genetic and biomedical advances over the
    past few years hold the promise for understanding the threats to
    healthy and full development and ultimately to the prevention and
    amelioration of the impact of many disabilities.
        Obesity.--NICHD is integrally involved in research into the origins
    of obesity in childhood. Next to tobacco use, diet and exercise
    represent the areas in which prevention efforts will have the greatest
    impact in reducing the socioeconomic and societal burdens of the
    obesity epidemic. More developmental research needs to be focused on
    understanding the interplay among behavioral, social and physical
    environment, and biological factors that lead to obesity so that
    effective and appropriate interventions can be developed earlier in the
    life cycle.
        Rehabilitation Research.--The NICHD houses the National Center for
    Medical Rehabilitation Research (NCMRR). This Center fosters the
    development of scientific knowledge needed to enhance the health,
    productivity, independence, and quality-of-life of people with
    disabilities. A primary goal of Center-supported research is to bring
    the health related problems of people with disabilities to the
    attention of the best scientists in order to capitalize upon the myriad
    advances occurring in the biological, behavioral, and engineering
    sciences.
        SIDS.--Though the NICHD has made remarkable progress in reducing
    the rate of SIDS, SIDS remains the leading cause of death in infants
    from 1 month of age to 1 year. More research and public education is
    needed to address the large number of babies dying of asphyxiation and
    suffocation in unsafe adult bed-sharing situations. Additional support
    is also needed to expand the work of NICHD's Stillbirth Collaborative
    Research Network, where for the first time we are finding answers that
    may ultimately lead to prevention of many of these 26,000 devastating
    losses, many of which are late term and yet unexplained.
    Conclusion
        The potential contributions of the Institute to the lives of
    countless individuals are limited only by the resources available for
    carrying out its vital mission. This is why the Friends of NICHD ask
    you to provide an appropriation of $1.495 billion to the Institute. Our
    Nation and the world will continue to benefit from your promise to
    improving health and scientific advancement long after the doubling
    effort is over.
        We thank you, Mr. Chairman, and the subcommittee, for your support
    of the Eunice Kennedy Shriver National Institute of Child Health and
    Human Development, and thank you for the opportunity to share these
    comments.
                                     ______

      Prepared Statement of The Friends of the National Institute on Aging

        Chairman Harkin and members of the subcommittee, thank you for the
    opportunity to provide testimony regarding the crucial role of the
    National Institute on Aging (NIA) within the National Institutes of
    Health (NIH) and the need for increased appropriations in the fiscal
    year 2011 budget to ensure sustained, long-term growth in aging
    research.
        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. As a coalition, 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 NIA.
        My testimony today demonstrates 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 (ARRA) for NIH research and training activities in fiscal year
    2011.
    The Relevance of the Work of the NIA
        NIH is the primary funder of biomedical research in this country
    and as such, NIA leads the Federal effort to advance biomedical and
    behavioral research in aging. NIA leads the national scientific effort
    to understand the nature of aging in order to promote the health and
    well-being of older adults. NIA's mission is three-fold: (1) Support
    and conduct genetic, biological, clinical, behavioral, social, and
    economic research related to the aging process, diseases and conditions
    associated with aging, and other special problems and needs of older
    Americans; (2) Foster the development of research- and clinician-
    scientists for research on aging; and (3) Communicate information about
    aging and advances in research on aging with the scientific community,
    healthcare providers, and the public. The NIA carries out this mission
    by supporting both extramural research at universities and medical
    centers across the United States and vibrant intramural research at the
    NIA's laboratories in Baltimore and Bethesda, Maryland. The work of the
    NIA focuses not only on diseases and conditions of aging but also on
    the processes underlying the aging process itself and as such, the
    research conducted by NIA-funded scientists has relevance for each and
    every person in America, regardless of age.
    Forward Momentum: ARRA Funding and the NIA
        The bolus of funding provided by ARRA has made it possible for NIA-
    funded researchers to make progress towards key research questions
    related to health and aging. As a result of ARRA funding, NIA-funded
    scientists have been able to intensify their research efforts in areas
    of critical importance to aging and health, including but not limited
    to the following:

    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Understanding how Alzheimer's Disease       Investigating the ways in
     develops and progresses.                    which Alzheimer's Disease
                                                 (AD) and vascular disease
                                                 may adversely affect one
                                                 other in the hopes of
                                                 identifying strategies for
                                                 preventing dementia.\1\
                                                Examining the ways that
                                                 energy metabolism
                                                 influences brain aging by
                                                 looking for correlations
                                                 among brain imaging
                                                 patterns, dementia, and
                                                 metabolic measures in aging
                                                 and in people with AD.\2\
    Identifying genetic and other risk factors  Using genome-wide
     for Alzheimer's Disease.                    association studies to
                                                 compare the genomes of
                                                 individuals with and
                                                 without AD to identify
                                                 potential genetic risk.\3\
    Seeking new ways of screening for and       Identifying best practices
     detecting Alzheimer's Disease.              for cerebrospinal fluid
                                                 sample collection and
                                                 attempting to identify AD
                                                 biomarkers in cerebrospinal
                                                 fluid before the onset of
                                                 symptoms.\4\
                                                Comparing the effectiveness
                                                 of brain imaging and blood
                                                 biomarkers to diagnose
                                                 AD.\5\
    Discovering possible prevention and         Elucidating the long-term
     treatment strategies for Alzheimer's        effect of naproxen and
     Disease.                                    other NSAIDS on cognitive
                                                 health by following
                                                 participants in the
                                                 Alzheimer's Disease Anti-
                                                 inflammatory Prevention
                                                 Trial (ADAPT) to.\6\
                                                Determining whether
                                                 compounds that manipulate
                                                 the histone code may have
                                                 therapeutic value for AD
                                                 and other neurological
                                                 disorders.\7\
    Enhancing neuroimaging methods and tools..  Developing software to
                                                 simplify the analysis of
                                                 complex brain-image data
                                                 relating to the structure
                                                 and function of the human
                                                 brain.\8\
                                                Developing a ``network
                                                 diagram'' that links
                                                 genetic information with
                                                 underlying brain circuitry
                                                 in the neural systems
                                                 controlling behavior and
                                                 emotion to improve our
                                                 understanding of the
                                                 connectivity of circuits
                                                 that are disturbed in
                                                 neurologic conditions,
                                                 including mental illness,
                                                 autism, Parkinson's
                                                 disease, Alzheimer's
                                                 disease, and addiction.\9\
    Preventing neuroinflammation..............  Developing a safe and
                                                 effective vaccine for the
                                                 treatment of AD that will
                                                 not cause an inflammatory
                                                 response in the brain.\10\
    Understanding the impact of economic        Examining trends in
     concerns on older adults.                   demography, economics,
                                                 health, and health care of
                                                 the elderly by evaluating
                                                 the effects of medical
                                                 technology on costs and
                                                 examining changes in
                                                 survival, health, and well-
                                                 being among older people
                                                 over time.\11\
                                                Examining the financial
                                                 circumstances of older
                                                 Americans, including work
                                                 and retirement behavior,
                                                 health and functional
                                                 ability, and policies that
                                                 influence individual well-
                                                 being.\12\
    Improving the quality of patient care.....  Evaluating the effectiveness
                                                 of feeding tubes in the
                                                 hospital setting to reduce
                                                 weight loss among older
                                                 adults with dementia.\13\
                                                Describing risk factors and
                                                 long-term consequences of
                                                 adverse medical events or
                                                 medical injuries among
                                                 older adults.\14\
    Preparing the next generation of            Recruiting and training
     researchers.                                doctoral-level students in
                                                 health services research to
                                                 prepare them for careers as
                                                 independent scientists.\15\
                                                Recruiting new faculty
                                                 members to enhance the
                                                 capacity for
                                                 transdisciplinary research
                                                 on aging that examines how
                                                 social context and the
                                                 healthcare system interact
                                                 to impact health outcomes
                                                 for older adults.\15\
    ------------------------------------------------------------------------
    \1\ 1 F32 AG031620-01A2--Nozomi Nishimura (NY).
    \2\ 3 K23 NS058252-04S1--Jeffrey Burns (KS).
    \3\ 2 R01 AG016208-10A2--Alison Goate (MO); 1 RC2AG036528-01--Gerard
      Schellenberger (PA); 1 RC2 AG036650-01--Denis A. Evans, Jill R.
      Murrell, and Philip De Jager (IL).
    \4\ 1 RC2 NS069502-01--Howard Schulman (NC); 1 RC1 AG035654-01--David
      Holtzman (MO).
    \5\ 1 RC1 AG036208-01--Orly Lazarov (IL).
    \6\ 2 U01 AG015477-06A2--John Breitner (WA).
    \7\ 1 RC1 AG035711-01--Li-Huei Tsai (MA).
    \8\ 2 R01 AG013743-13A1--Edward Herskovits. (PA).
    \9\ 1 RC1 NS069152-01--Julie R. Korenberg (contact), Tolga Tasdizen
      (UT).
    \10\ 3 R01 AG20159-08S1--Cynthia Lemere (MA).
    \11\ 3 P30 AG017253-10S1--Alan Garber (CA).
    \12\ 3 P30 AG012810-16S1 and 16S2--David A. Wise (MA).
    \13\ 1 RC1 AG036418-01--Joan Teno (RI).
    \14\ 1 R21 AG031983-01A1--Mary Carter (WV).
    \15\ 2 T32 AG023482-06--Vincent Mor (RI).
    \16\ 1 P30 AG036459-01--David Meltzer (IL).

        With a sustained investment in the NIH funding base, these and
    other NIA-funded projects will yield breakthroughs in the screening,
    prevention and treatment of a host of age-associated diseases and
    conditions. With the fiscal year 2011 budget, Congress has the
    opportunity to increase the forward momentum of NIA-funded scientists
    towards achieving these much-needed breakthroughs.
    The Challenges and Opportunities Ahead
        A key challenge is maintaining the positive momentum set into
    motion by Congress through ARRA. Between fiscal year 2003 and fiscal
    year 2009, scientists saw a series of nominal increases and cuts that
    amounted to flat funding for NIH and a 12.9 percent reduction in
    constant dollars for the NIA. Six years of flat funding for the NIH
    took a toll on scientific progress in America--projects were sidelined,
    promising grants went unfunded, and countless life-saving discoveries
    went undiscovered. With the infusion of funding from ARRA NIH
    researchers are regaining some of the ground lost during that time
    period. NIA is poised to accelerate the scientific discoveries that we
    as a nation are counting on America's leading researchers to achieve.
    With millions of Americans facing the loss of their functional
    abilities, their independence, and their lives to diseases like
    Alzheimer's Disease, Parkinson's Disease, Amyotrophic Lateral
    Sclerosis, and Frontotemporal Dementia, there is a pressing need for a
    robust and sustained investment in the work of NIH and by extension,
    NIA. In every community in America, healthcare providers depend upon
    NIA-funded discoveries to help their patients and caregivers lead
    healthier and more independent lives. In those same communities across
    America, parents are hoping NIA-funded discoveries will help their
    children have a brighter future, free from the diseases and conditions
    of aging that plague our Nation today.
        We do not yet have the knowledge needed to predict, pre-empt, and
    prevent the broad spectrum of diseases and conditions associated with
    aging. We do not yet have the knowledge needed about disease processes
    to understand how best to prevent, diagnose, and treat diseases and
    conditions of aging, nor do we have the knowledge needed about the
    complex relationships between biology, genetics, and behavioral and
    social factors related to aging. We do not yet have a sufficient pool
    of new investigators entering the field of aging research. Bold,
    visionary, and sustainable investments in the NIA will make it possible
    to achieve measurable gains in these areas sooner rather than later.
        The member groups of the Friends of the National Institute of Aging
    respectfully urge this subcommittee to provide sustained support for
    biomedical and behavioral research by increasing NIA funding by a
    minimum of 7 percent in fiscal year 2011 to correspond with the overall
    funding increase to NIH. NIA and the health-enhancing and life-saving
    biomedical, behavioral and social research it supports require bold,
    visionary, and sustainable funding to succeed in transforming the
    health of our Nation. Americans depend upon the NIA to facilitate the
    acceleration of discoveries to prevent, treat, and potentially cure a
    wide range of debilitating age-related diseases and conditions. NIA-
    supported scientists are poised to make breakthroughs in the prevention
    and treatment of a host of age-associated diseases and conditions, but
    in order to achieve these powerful results, meaningful investments in
    aging research must be made now.
        While the Friends of the NIA recognizes that there is enormous
    competition for congressional appropriations, we believe that an
    increase in funding for the NIH will yield unprecedented returns in
    terms of accelerating the rate of basic discovery and stimulating the
    rapid development of interventions with the potential to offer
    significant public health benefits for our aging population.
        Mr. Chairman, the Friends of the NIA thanks you for this
    opportunity to outline the challenges and opportunities that lie ahead
    as you consider the fiscal year 2011 appropriations for the NIH. We
    would be happy to furnish additional information upon request.
                                     ______

                  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 & CEO of the FSH Society, Inc.
    (facioscapulohumeral muscular dystrophy) and as an individual who has
    this common and most prevalent form of muscular dystrophy. 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 (FSHD) and
    the urgent need for increased National institutes of Health (NIH)
    funding for research on this disorder. 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.
    FSHD is The Most Prevalent Form of Muscular Dystrophy
        It is a fact that FSHD is published in the scientific literature as
    the most prevalent muscular dystrophy in the world. The incidence of
    FSHD is conservatively estimated to be 1 in 14,000. The prevalence of
    the disease, those living with the disease, ranges to 2 or 3 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 U.S.
    National Institutes of Health (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'' November 2008--Issue 10 report can
    be found at Internet Web site (http://www.orpha.net/orphacom/cahiers/
    docs/GB/Prevalence_of_rare_diseases_by_alphabetical_list.pdf). This
    publication 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 form of
    muscular dystrophy.

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

    NIH Muscular Dystrophy Funding Has Quadrupled Since Inception of the MD
            CARE Act
        Figures from the online RCDC RePORT and the NIH Appropriations
    History for Muscular Dystrophy report historically provided by NIH/OD
    Budget Office & NIH OCPL show that from the inception of the MD CARE
    Act 2001, funding has nearly quadrupled from $21 million to $83 million
    in fiscal year 2009 for muscular dystrophy.
    NIH Funding of FSHD has Remained Level Since the Inception of the MD
            CARE Act
        In fiscal year 2009, FSHD was 6.02 percent of the total muscular
    dystrophy funding ($5 million/$83 million). The previous year FSHD was
    5.3 percent of the total muscular dystrophy funding ($3 million/$56
    million). FSHD funding has simply kept its ratio in the NIH funding
    portfolio and has not grown in the last 8 years.

                      NIH FSHD FUNDING ANMD APPROPRIATIONS
                              [Dollars in millions]
    ------------------------------------------------------------------------
                                                                   FSHD
                    Fiscal year                FSHD research   percentage of
                                                                    MD
    ------------------------------------------------------------------------
    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
    2009....................................               5               6
    ------------------------------------------------------------------------
    Sources: NIH/OD Budget Office, NIH OCPL, and NIH RCDC RePORT.

        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.
    FSHD: The Most Prevalent Form of Muscular Dystrophy is Drastically
            Underfunded at NIH
        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 credibility that
    it still remains the most prevalent and one of the most underfunded
    dystrophies at the NIH and in the Federal research agency system (CDC,
    DOD, and FDA).
        In 2009, the most prevalent muscular dystrophy, FSHD, received $5
    million from NIH. In 2009, the second most prevalent dystrophy,
    Duchenne (DMD) and Becker Muscular dystrophy (BMD) type, received $33
    million from NIH. In 2009, the third most prevalent dystrophy myotonic
    dystrophy (DM), received $13 million from NIH.
        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 8
    years muscular dystrophy has quadrupled to $83 million and that FSHD
    has remained on average at 5 percent of the NIH muscular dystrophy
    portfolio. FSHD is certainly still far behind when we look at the
    breadth of research coverage NIH-wide.
        It is now time to examine why FSHD receives such a disproportional
    and inverse level of funding despite its equal burden of disease and
    highest prevalence. It is crystal clear, if not completely black and
    white, that we are not achieving the goals of parity in funding as
    expected by the mandates set forth in the MD CARE Acts 2001/2008 and by
    the NIH Action Plan for the Muscular Dystrophies as submitted to the
    Congress by the NIH.
        We would like to commend the program staff at the NIH for the
    excellent progress made in FSHD and the extraordinary progress made in
    increasing muscular dystrophy funding. We are very pleased with the
    efforts of NIH staff and Muscular Dystrophy Coordinating Committee
    (MDCC) on behalf of the community of patients and their families with
    muscle disease and the research community pursuing solutions for all of
    us. We recognize in particular the efforts and hard work of the
    following NIH staff: Story Landis, Ph.D., Executive Secretary, MDCC and
    Director, National Institute of Neurological Disorders and Stroke
    (NINDS); John D. Porter, Ph.D., Executive Secretary, MDCC and Program
    Director, Neuromuscular Disease, Neurogenetics Cluster and the
    Technology Development Program, NINDS; Stephen I. Katz, M.D., Ph.D.,
    Director, National Institute of Arthritis and Musculoskeletal and Skin
    Disease (NIAMS); Glen H. Nuckolls, Ph.D., Extramural Programs,
    Musculoskeletal Diseases Branch, NIAMS; James W. Hanson, M.D., Director
    of the Center for Developmental Biology and Perinatal Medicine, Eunice
    Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD); and, Ljubisa Vitkovic, M.D., Ph.D., Mental
    Retardation and Developmental Disabilities Branch, DHHS NIH NICHD.
        Efforts of excellent program staff and leadership at NIH, excellent
    reviewers and study sections, excellent and outstanding researchers
    both 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 requests, contracts ands 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 in more than 20 years
    despite consistent pressure from appropriations language and
    Appropriations Committee questions, and an authorization from Congress
    mandating research on FSHD.
        The pace of discovery and numbers of leading experts in the field
    of biological science and clinical medicine working on FSHD are very
    rapidly expanding. Many leading experts are now turning to work on FSHD
    not only because it is one of the most complicated and challenging
    problems seen in science, but because it represents the potential for
    great discoveries, insights into stem cells and transcriptional
    processes and new ways of treating human disease.
    Areas of Scientific Opportunity in FSHD That Need NIH Funding
        The majority of the international FSHD clinical and research
    community recently came together at the DHHS NIH NICHD Boston
    Biomedical Research Institute Senator Paul D. Wellstone MD CRC for
    FSHD. Almost 90 scientists working on FSHD globally met at the 2009 FSH
    Society FSHD International Research Consortium, held on Monday,
    November 9, 2009, and Tuesday, November 10, 2009. The summary and
    recommendations of the group state the following:
        During the past two decades, the FSHD research has made steady
    progress to unravel the molecular basis of this common muscle disease.
    The main line of research has focused on the extremely complex
    (epi)genetic enigma. This complexity has fascinated experts involved in
    related research. At the present moment the FSHD research field is
    covering a variety of multidisciplinary and complementary approaches.
    Although the exact details of the molecular genetic basis of FSHD are
    still not in place, the general picture is coming into focus. Within 1-
    2 years, evidence-based intervention strategies are on the drawing-
    board and trials are planned. To be prepared for this new FSHD era, we
    need to accelerate the efforts in the following areas--
                Patients and Clinical Trials Readiness
        There is a need for well-characterized registries with uniform data
    collection. NIH U54 Wellstone MD CRC, NIH registries, and patient
    organizations are key to this process. These groups and registry and
    patient organizations are instrumental for:
      --Work on natural history--identification of phenotype modifiers
            (genetic and environmental)
      --Identification of the FSHD2 gene (contraction-independent FSHD)
      --Bio-banking (cell lines etc.)
      --Development of tools and assays to measure clinical trials
            endpoints
                Epigenetics/Genetics
        This line of work will be instrumental to pinpoint the real
    identity of FSHD1A (chromosome-4-linked cases) and FSHD1B
    (nonchromosome-4-linked cases). This information will form the basis
    for evidence-based intervention.
      --Modifying genes for FSHD1 (large inter-individual variation in
            symptoms)
      --Identify the FSHD2 gene (common molecular pathway with FSHD1)
      --Further work on the chromatin structure/function relationship
                Biomarkers for Clinical Therapy
        There is obvious need for monitoring intervention.
      --Systems biology approaches
        --transcriptomics, proteomics, metabolomics, etc.
      --In situ (RNA, protein) to detect cellular heterogeneity
      --Non-invasive monitoring (MRI etc.)
                Model Systems
        Urgent need for more specific model systems for mechanistic,
    intervention work and advancement to clinical trials.
      --Cellular models
        --Biopsies--for well characterized FSHD cell lines
        --Mosaics--isogenic and clonal lines
        --Induced pleuropotent stem cells (iPS)
      --Animal
        --Mouse--inducible/humanized mouse etc.
        --Other species
                Molecular, Cellular, and Genomic
        Myogenesis in normal and FSHD muscle (myoblasts/myotubes)
        Cell cycling
        Dynamics of muscle satellite cells
        RNA iso-forms and alternative splicing (FRG1, DUX4, others)
        --Genome wide (normal versus FSHD)
        Chromatin structure at 4q35
        Downstream gene targets
               our request to the nih appropriations subcommittee
        We request this year in fiscal year 2011, immediate help for those
    of us coping with and dying from FSHD. We ask NIH to fund research on
    facioscapulohumeral muscular dystrophy (FSHD) at a level of $25 million
    in fiscal year 2011.
        We implore the Appropriations Committee to request that the
    Director of NIH, the Chair, and Executive Secretary of the Federal
    advisory committee Muscular Dystrophy Coordinating Committee mandated
    by the MD CARE Act 2008, to increase the amount of FSHD research and
    projects in its portfolios using all available passive and pro-active
    mechanisms and interagency committees.
        We ask that Congress ask NIH to consider increasing the scope and
    scale of the existing DHHS U.S. NIH Senator Paul D. Wellstone Muscular
    Dystrophy Cooperative Research Centers (U54) to double or triple their
    size--they are financially under-powered as compared to their
    potential. These centers have provided an excellent catalyst for
    progress in funding and a greater seriousness in the endeavor of
    treating muscular dystrophy. We ask Congress to request of NIH the
    development of mechanisms to help expand work from the center of the
    NIH Wellstone Centers outward to address needs and priorities of the
    scientific communities.
        Given the knowledge base and current opportunity for breakthroughs
    in treating FSHD it is inequitable that only 4 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 facioscapulohumeral muscular dystrophy. Our
    successes are continuing and your support must continue and increase.
        Mr. Chairman, thank you for this opportunity to testify before your
    subcommittee.
                                     ______

                   Prepared Statement of Family Voices, Inc.

        I am grateful for this opportunity to submit written testimony on
    behalf of Family Voices, Inc., an organization of families whose
    children have special healthcare needs and/or disabilities. Family
    Voices aims to achieve family-centered care for all children and youth
    with special healthcare needs and/or disabilities. Through our national
    network, we provide families tools to make informed decisions, advocate
    for improved public and private policies, build partnerships among
    professionals and families, and serve as a trusted resource on
    healthcare.
        Family Voices respectfully asks the subcommittee to provide $10
    million in funding for Family-to-Family Information Centers (F2F HICs)
    for Federal fiscal year 2011. In addition, we request that funding for
    the title V Maternal and Child Health Services Block Grant be increased
    to $730 million for Federal fiscal year 2011.

                  FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS

        F2F HICs are statewide, family-led information and referral centers
    that provide families with information about how to obtain and finance
    healthcare for their children/youth with special healthcare needs
    (CYSHCN), including disabilities and chronic medical conditions like
    cerebral palsy, epilepsy, or asthma. The Deficit Reduction Act of 2005
    mandated that Federal grants be provided ($3 million in fiscal year
    2007, $4 million in fiscal year 2008, and $5 million in fiscal year
    2009) to create a F2F HIC in every State and the District of Columbia
    by fiscal year 2009. The Patient Protection and Affordable Care Act
    provided $5 million in each of fiscal years 2010-2012 to maintain these
    F2F HICs at their current levels of funding.
        The needs of CYSHCN are chronic and complex and, thus, securing and
    paying for their care is often a struggle. F2F HICs provide life-
    altering information to families in crisis; simply enrolling in
    Medicaid for a newborn in need of expensive critical care can be an
    arduous task. Most of the staff at F2F HICs are members of families
    whose children have special healthcare needs. This unique perspective
    allows them to provide advice, offer a multitude of resources, and tap
    into a network of other families and professionals for support and
    information. In addition, they help healthcare providers to understand
    the various public programs available for their patients, and assist in
    dealing with private insurers. In fact, about one-third of requests to
    F2F HICs are from healthcare professionals. The centers also aim to
    ensure that each child has a ``medical home,'' and that partnerships
    are built between healthcare professionals and the families of CYSHCN,
    thereby improving the quality of care.
        At the present level of funding--$5 million total--each site
    receives only $95,700 per year. Although hundreds of thousands of
    families are being served by F2F HICs, the level of funding is not
    sufficient to serve all of the families and providers who need
    assistance in each State. As discussed in more detail below, an
    increase to $10 million is needed to assist more families of CYSHCN and
    healthcare providers who need these services; to expand training and
    technical assistance to grantees; and to make these valuable services
    available to additional regions and populations. Moreover, the
    healthcare system navigation function provided by F2F HICs will be of
    increased importance now that healthcare reform has been enacted.
        There is a great need for Family-to-Family Health Information
    Centers (F2F HICs).
        An estimated 22 percent of U.S. household with children have at
    least one child with special healthcare needs--that is more than 10
    million children--and that number appears to be growing. Among these
    families, 38 percent do not have adequate insurance to pay for services
    their children need; 20 percent of these families pay $1,000 or more
    per year in out-of-pocket expenses. These problems are exacerbated
    among families of ethnic, racial, and cultural minorities because their
    access to coverage and care is significantly more limited.
        It is very difficult for families to figure out how to finance
    their children's care, given the great expense and complexity of
    potential funding sources--private insurance, Medicaid, SCHIP, State
    Maternal and Child Health programs, the school system--each with
    different eligibility and coverage criteria. It can also be difficult
    to find sources of care, given the shortage and maldistribution of
    pediatric subspecialists.
        Additional funding is needed to sustain the current scope of work,
    and to expand F2F HICs to territories and tribal organizations.
        Currently, F2F HICs are being funded at $5 million. This money
    funds 51 existing centers, one in each State and one in the District of
    Columbia, at approximately $95,700 a year--barely enough to cover one
    staff member or two part-time employees, and not enough to serve all
    the families who need assistance. All States could use more funding to
    reach more families. States with large populations in particular need
    larger grants in order to serve the families within their States.
        In addition, the number of centers should be expanded to serve
    territories and Native American populations, which have their own
    unique healthcare systems. It is anticipated that over the next several
    years, 10 new grantees could be established in order to meet the needs
    of these distinct populations. These new grantees would require
    operating funds, and would necessitate additional costs for oversight
    and technical assistance.
        Additional funding is needed to provide technical assistance to
    grantees.
        There are currently no designated dollars to provide structured
    technical assistance to funded F2Fs. A very small amount of the funds
    remaining after State distributions ($21,000 in the past year) has been
    used to assist in planning and coordinating a technical assistance
    meeting. Substantial technical assistance for developing, assisting and
    coordinating F2F programs, provided through a national, experienced,
    family-run organization, in coordination with regional family-run
    organizations, is needed to grow the capacity and ensure the quality of
    the F2Fs to best meet the needs of families of CYSHCN navigating
    complex healthcare systems.
        Healthcare reform will further necessitate the services of F2F
    HICs.
        Healthcare reform will require the services of the F2F HICs more
    than ever, as families whose children have special healthcare needs
    attempt to maneuver a new and complex system of insurance and care. The
    F2Fs HICs are expert in the unique needs of this sizeable population.
    Family-to-Family Health Information Centers within each State will be
    the best-positioned organizations to serve as navigators for families
    of CYSHCN--a role that has been identified in healthcare reform bills
    as necessary to ensure that the goals of the reform are met and
    maximized.
        F2F HICs receive less funding than a comparable educational
    assistance program--Parent Training and Information Centers.
        Over 25 years ago, the Federal Government recognized the
    complexities faced by families whose children need or might need
    special education services, and created a nationwide system of support
    and technical assistance for these families--Parent Training and
    Information Centers (PTIs).
        Families with children who have special healthcare needs face equal
    and additional challenges when faced with maneuvering the healthcare
    system--a system much more complex than the special education system,
    which is governed by one law (IDEA), whereas the healthcare system
    consists of a myriad of private and public insurance programs,
    benefits, waivers, limitations, networks, and cost-sharing.
        In fiscal year 2009, the PTIs were funded at $27 million, versus
    the $5 million in funding for the F2F HICs, despite the fact that they
    serve a very similar population.
        The F2F HIC program has demonstrated its effectiveness and value.
        Although they operate on shoe-string budgets, F2F HICs are able to
    help many families: from July 2008 to May 2009, the 41 F2F HICs then in
    existence trained and assisted more than 665,000 families of CYSHCN by
    helping them to navigate community services, partner with health
    professionals, find financing for care, and access a medical home. In
    addition, F2F HICs trained and assisted over 320,000 healthcare
    professionals in helping families with CYSHCN. On average, each F2F HIC
    collaborated with 14 State-level programs and 10 community-based
    organizations.
        The value and potential of F2F HICs has been established by outside
    evaluators:

        ``Family-to-Family Centers nationwide provide important information
    and assistance to families of CYSHN as well as the professionals who
    care for them, often with very limited staff and resources.''--Thomson
    Medstat, June 2006
        ``By helping families to provide a consumer perspective on program
    and policy issues, F2F HICs are helping States to develop more
    effective ways to assist families with CYSHCN. Ultimately, the F2F HICs
    goal is to improve health and functional outcomes for families with
    CYSHCN. To the extent families understand what is available for their
    children and use services effectively, outcomes for their children will
    improve. These benefits go well beyond the children and families.
    Children whose outpatient needs are met and whose parents are able to
    meet their daily care needs are less likely to require hospital or
    emergency room care. Children who obtain home and community long-term
    care services are less likely to need costly institutional care.
    Congress has recognized the value of F2F HICs by authorizing funds to
    establish one in every State. These highly effective organizations
    require a stable source of funding to sustain outreach and referral
    services, information development and dissemination, and education and
    training initiatives.''--Research Triangle Institute, April 2006.

        Perhaps more compelling are the stories of families who have been
    assisted by F2F HICs. An example is provided from Louisiana, where the
    F2F HIC assisted a family who had two children with severe
    disabilities. Both children had private health insurance and Medicaid
    for secondary coverage. The private health insurance company began
    requiring their enrollees to use an out-of-State mail-order pharmacy
    for their regularly renewed medications. This meant that the family was
    no longer able to use Louisiana Medicaid as a secondary insurer because
    the out-of-State pharmacy was not a Louisiana Medicaid provider. The
    family was faced with over $500 per month in additional costs because
    they could not access their Medicaid coverage. The Louisiana F2F HIC
    worked with the State Medicaid Director so that this family could
    submit the balance of the costs and receive their sorely needed
    benefits.
        For the above reasons, we respectfully request that a $10 million
    appropriation be provided for F2F HICs for fiscal year 2011.

                 TITLE V MATERNAL AND CHILD HEALTH BLOCK GRANT

        As you know, one of the missions of the title V Maternal and Child
    Health Block Grant is to serve children with special healthcare needs.
    State MCH programs for CYSHCN help to build an infrastructure to ensure
    the provision of family-centered, community-based coordinated care for
    children with chronic conditions and disabilities. They have strong
    connections to pediatric specialists and the best available data on the
    needs of these children and their families. Due to years of reduced
    investment, however, the MCH Block Grant is at its lowest funding level
    since 1993, $662 million. The program--and the populations it serves--
    deserves increased funding to fulfill its valuable missions. Therefore,
    Family Voices respectfully requests that the Congress provide $730
    million for the Title V Maternal and Child Health Block Grant program
    for fiscal year 2011.
                                     ______

            Prepared Statement of Goodwill Industries International

        Mr. Chairman, Ranking Member, and members of the subcommittee, on
    behalf of Goodwill Industries International (GII), I appreciate this
    opportunity to submit written testimony on Goodwill's priorities for
    funding programs administered by the U.S. Departments of Labor, Health
    and Human Services, and Education.
        GII represents 159 local and autonomous Goodwill Industries
    agencies in the United States that help people with barriers to
    employment to participate in the workforce. One of Goodwill Industries'
    greatest strengths continues to be its entrepreneurial approach to
    sustaining its mission. In 2008, the Goodwill Industries network raised
    nearly $3.7 billion through its retail, contracts, and mission services
    operations. Nearly 83 percent of the funds Goodwill Industries raised
    in 2009 was used to supplement government investments, resulting in
    nearly than 2 million different people served by local Goodwill
    agencies, including more than 155,000 job placements. In addition to
    our efforts to help people find jobs and advance in careers, Goodwill
    understands that many people need additional supportive services--child
    care, reliable transportation, stable housing, counseling, and
    assistance in adjusting to the workplace, assistive technology--to
    ensure their success.
        Especially during such trying economic times, Goodwill Industries
    understands the difficult challenge that appropriators face as they
    struggle to stretch limited resources to support an ever-increasing
    list of national priorities. As the Nation struggles to recover from
    the worst recession since the Great Depression and unemployment
    stubbornly hovers near 10 percent, Goodwill Industries' remains
    committed to partnering with stakeholders at the Federal, State, and
    local levels by contributing the resources and expertise of local
    Goodwill agencies in support of public efforts and investments.
        While our agencies care about a range of Federal funding streams,
    GII believes that Federal investment in the Workforce Investment Act,
    Vocational Rehabilitation, the Senior Community Service Employment
    Program (SCSEP), Green Jobs, and TANF will help the Goodwill network to
    do more for the people in communities across the country who are
    struggling to overcome employment barriers. Furthermore, Goodwill
    supports the administration's proposal to increase funding to
    strengthen enforcement of wage and hour standards. Goodwill urges
    Congress to provide adequate funding in fiscal year 2011 for these
    critical programs.
    Workforce Investment Act
        Funding for the Workforce Investment Act's adult, dislocated
    worker, and youth formulas is one of Goodwill's top funding priorities
    for fiscal year 2011. Goodwill agencies and their community partners
    are on the front lines of this recovery effort assisting people with
    employment barriers, including individuals with disabilities, older
    workers, and welfare recipients who are struggling to find and keep
    jobs at a time when unemployment is at its highest rate experienced in
    a generation.
        Of the nearly 2 million people served by local Goodwill agencies in
    the United States in 2009, nearly 160,000 people were referred to local
    Goodwill agencies for employment services through the Workforce
    Investment Act (WIA) and State Vocational Rehabilitation agencies. Many
    local Goodwill agencies are one-stop lead operators, or operators in
    association with other service providers, and are active on State and
    local workforce boards.
        As members of this Subcommittee know, the administration's fiscal
    year 2011 budget proposes to launch a Workforce Innovation Fund to
    ``support and test promising approaches to training, and breaking down
    program silos, building evidence about effective practices, and
    investing in what works.'' Goodwill believes that this idea is
    promising, is very interested in the details, and is encouraged by the
    Administration's efforts to increase interagency collaborations and
    leverage resources provided by community-based organizations.
        Goodwill strongly believes, however, that the proposed Workforce
    Innovation Funds should be paid for with funds in addition to, rather
    than at the expense of, existing WIA formula funds--in fiscal year 2011
    and beyond. We understand that this subcommittee's funding allocation
    will be extremely tight as a result of the President's call for a
    discretionary budget freeze. However, it should be noted that the
    President's budget request for WIA programs is 7 percent less in actual
    dollars than in fiscal year 2002, a time when the unemployment rate was
    less than half of what jobseekers are experiencing today.
        Goodwill believes that the workforce system is vastly underfunded
    and that the preservation of WIA's formula funding streams should be a
    high priority. Therefore, Goodwill urges Congress to sustain WIA's
    adult, dislocated worker, and youth funding streams at current funding
    levels at a minimum before dedicating funding to the administration's
    proposed WIA Innovation Fund.
    VR Funding
        Goodwill Industries has a long history of helping people with
    disabilities to participate in the workforce despite the challenges
    their disabilities present. Years of inadequate funding for Vocational
    Rehabilitation have left the system stretched much too thin to serve
    all who are eligible for assistance. As a result, more than half of the
    80 State VR agencies have Orders of Selection, a provision within the
    Rehabilitation Act that requires State VR agencies, when faced with a
    shortage of funds to meet the demand for services, to prioritize the
    provision of services to eligible people based on the severity of
    people's disabilities. In addition, reduced funding for WIA has placed
    an additional strain on mandatory partner programs, including VR, which
    are being asked to contribute more funding to pay for infrastructure
    and other costs associated with the operation of one-stop centers.
        Goodwill Industries supports the President's intent to increase
    multi-system collaboration and support for youth with disabilities who
    are transitioning from education to the workforce. However, Goodwill is
    concerned that the President's fiscal year 2011 budget proposal would
    consolidate VR programs in order to achieve these goals. First, the
    President proposes to eliminate VR's supported employment State grant
    program to create a supported employment program for youth who are
    transitioning from education to the workforce. For more than two
    decades, Goodwill has offered supported employment as a part of its
    service array. According to GII's Annual Statistical Report,
    participation in local Goodwill agencies' supported employment programs
    has grown dramatically in recent years from providing 270,000 coaching
    sessions in 2007 to 630,000 sessions in 2009.
        Furthermore, the administration's budget proposes to eliminate
    funding for VR's Projects With Industry and the migrant and seasonal
    farmworker program. The administration asserts that services provided
    by these programs will continue under the VR State grants funds and
    would eliminate duplication. The resulting savings would be used to
    help pay for increased collaboration between the Department of
    Education, the Department of Labor and other agency heads. As noted
    earlier, Goodwill is intrigued by the administration's proposal to
    stimulate system collaboration by creating a Workforce Innovation Fund;
    however, Goodwill opposes paying for the Workforce Innovation Fund by
    eliminating or reducing funding for critical programs for people with
    barriers to employment. Therefore, Goodwill urges you to preserve
    funding for VR.
    Senior Community Service Employment Program (SCSEP)
        According to the Bureau of Labor Statistics, the unemployment rate
    for older workers older 65 years old is at the highest levels since the
    Department started keeping records in 1948. The Senior Community
    Service Employment Program (SCESP) helps provide low-income older
    workers with community services employment and private sector job
    placements. Goodwill is one of the newest SCSEP grantees. In 2009,
    SCSEP participants contributed nearly 1.2 million community service
    hours and our private sector placements averaged a starting wage of
    $8.67 per hour. In addition, as a result of the Recovery Act, which
    allowed Goodwill to start enrolling more participants in April 2009,
    SCSEP participants provided and additional 140,000 community service
    hours and our private sector placements started at $8.31 per hour.
        Goodwill recognizes and very much appreciates the monumental
    investment that the Congress has placed on helping older workers to
    survive the economic crisis. Congress has demonstrated its commitment
    to older workers by providing an additional $120 million for SCSEP in
    the Recovery Act, and a $250 million increase in fiscal year 2010.
    These funds have allowed local Goodwill agencies to better address our
    waiting list of participants and help many more older workers with
    part-time employment.
        Goodwill is concerned that the President's budget seeks to cut this
    program by 27 percent, as these older workers have multiple barriers to
    employment and will be among the last rehired as the economy improves.
    Goodwill urges the subcommittee to reject the administration's proposed
    cuts to SCSEP. At a minimum Congress should sustain funding for SCSEP
    at its fiscal year 2010 level, $825 million, so that the program can
    continue to better meet the needs of the increasing number of low-
    income older workers.
    Green Jobs
        Goodwill believes that the green jobs sector has great potential
    for increasing employment opportunities in high-growth fields for
    people with employment barriers and many Goodwill agencies are helping
    workers learn skills that will help them secure jobs in energy
    efficiency and alternative energy industries. We greatly appreciated
    the subcommittee's inclusion of $500 million for sectoral initiatives
    focused on green-related industries in the Recovery Act, and are
    thrilled that Goodwill Industries International and four local Goodwill
    agencies have been selected by DOL to provide training and placement in
    the renewable energy and energy efficiency sectors. Goodwill urges you
    to appropriate $85 million for green jobs as requested by the
    administration.
    Enforcement of Wage and Hour Standards
        Goodwill favors increased enforcement of the Fair Labor Standards
    Act, specifically section 14(c) which allows for the use of a special
    minimum wage certificate to employee individuals with disabilities that
    directly impair their productivity. As such, Goodwill supports the
    President's budget proposal of $244.2 million and 1,672 full-time
    employees for the Wage and Hour Division to support targeted
    investigations focusing on industries where misclassification is
    common.
        Goodwill thanks you for considering these requests, and looks
    forward to working with you to help government meet the serious
    challenges our Nation faces.
                                     ______

         Prepared Statement of the Hepatitis Appropriation Partnership

        The Hepatitis Appropriations Partnership (HAP) is a coalition that
    represents hepatitis community-based organizations, public health
    officials, health providers, national hepatitis and HIV organizations,
    and diagnostic, pharmaceutical and biotechnology companies. We work
    with policy makers and public health officials to increase Federal
    leadership and support for viral hepatitis prevention, testing,
    education, research, medical management, and treatment.
        As you craft the fiscal year 2011 Labor, Health and Human Services,
    and Education, and Related Agencies Appropriations legislation, we urge
    you to consider the following critical funding needs of viral hepatitis
    programs:
        Specific funding needs:
      --We are requesting an increase of $30.7 million for a total of $50
            million for the Centers for Disease Control and Prevention
            (CDC) Division of Viral Hepatitis (DVH);
      --At least $20 million for an adult hepatitis B vaccination
            initiative through the CDC section 317 Vaccine Program;
      --$10 million for the Substance Abuse and Mental Health Services
            Administration (SAMHSA) to fund a project within the Programs
            of Regional and National Significance (PRNS) to reach persons
            who use drugs with viral hepatitis prevention services;
        General funding needs:
      --Increase funding for Community Health Centers to increase their
            capacity to serve people with chronic viral hepatitis;
      --Increase funding for the Ryan White Program to adequately cover
            persons co-infected with viral hepatitis through additional
            case management, provider education, and coverage of viral
            hepatitis drug therapies;
      --Increase funding for the National Institutes of Health to support
            their Action Plan for Liver Disease Research
                             specific funding needs
    Division of Viral Hepatitis
      --Fiscal year 2011 request: $30.7 million
        The recently released Institute of Medicine (IOM) report, Hepatitis
    and Liver Cancer: A National Strategy for Prevention and Control of
    Hepatitis B and C found that the public health response needs to be
    significantly ramped up. The IOM report attributes low public and
    provider awareness to the lack of public resources. Seventeen of the 22
    recommendations in the report are specific to CDC DVH and State health
    departments. In order to implement these recommendations to improve the
    Federal response, resources must be increased to health departments
    which are the backbone of the Nation's public health system and
    coordinate the response to these epidemics.
        President Obama's budget proposal includes a $1.8 million increase
    for the DVH at CDC, which is woefully insufficient to address
    infectious diseases of this magnitude. While operating on the smallest
    Division budget for the prevention of infectious diseases within CDC,
    DVH will never be able to sufficiently prevent and manage these
    epidemics under its current fiscal constraints. States and cities
    receive an average funding award from DVH of $90,000. This is only
    enough for a single staff position and is not sufficient for the
    provision of core prevention services. These services are essential to
    preventing new infections, increasing the number of people who know
    they are infected, and following up to help those identified to remain
    healthy and productive. We believe this increase is an important first
    step to making hepatitis prevention services more widely available. The
    expanded services should include hepatitis B and C education,
    counseling, testing, and referral in addition to delivering hepatitis A
    and B vaccine, and establishing a surveillance system of chronic
    hepatitis B and C.
    Section 317 Vaccine Program
      --Fiscal year 2011 request: $20 million
        CDC identified funds through program cost savings in the section
    317 Vaccine Program, allocating $20 million in fiscal year 2008 and $16
    million in fiscal year 2009 for purchase of the hepatitis B vaccine for
    high-risk adults. We commend CDC for prioritizing high-risk adults with
    this initiative, but relying on the availability of these cost savings
    is not enough. Additionally, this initiative does not support any
    infrastructure or personnel and health departments need additional
    funding to support the delivery of this vaccine. We request a
    continuation of $20 million in fiscal year 2011 for an adult hepatitis
    B vaccination initiative through the CDC's section 317 Vaccine Program.
    Substance Abuse and Mental Health Services Administration
      --Fiscal year 2011 Request: $10 million
        Persons who use drugs are disproportionately impacted by hepatitis
    B and C. The Substance Abuse and Mental Health Services Administration
    (SAMHSA) Center for Substance Abuse Prevention (CSAP) and Center for
    Substance Abuse Treatment are uniquely positioned to reach populations
    at risk for hepatitis B and C. The existing infrastructure of substance
    abuse prevention and treatment programs in the United States provides
    an important opportunity to reach Americans at risk or living with
    viral hepatitis. We urge you to provide $10 million to SAMHSA to fund a
    project within the Programs of Regional and National Significance
    (PRNS) to reach persons who use drugs with viral hepatitis prevention
    services.

                             GENERAL FUNDING NEEDS

    Medical Management and Treatment
        Access to available treatments and support services are critical to
    combat viral hepatitis mortality. While we are supportive of the
    President's efforts to modernize and expand access to healthcare, we
    also support increased funding for existing safety net programs. Low-
    income patients who are uninsured or underinsured can and do seek
    services at Community Health Centers (CHCs). With the growing
    importance of CHCs as a safety net in providing frontline support for
    these individuals, we support increasing resources for CHCs to increase
    their capacity to serve people with chronic viral hepatitis.
        Many low-income individuals co-infected with viral hepatitis and
    HIV can obtain services through the Ryan White Program, however only
    half of the State AIDS Drug Assistance Programs (ADAPs) are able to
    provide viral hepatitis treatments to co-infected clients. We urge you
    to increase Ryan White funding so States can provide adequate coverage
    for co-infected clients. Increased resources are also needed to improve
    provider education on viral hepatitis medical management and treatment,
    to cover additional case management for patients undergoing treatment
    and to allow more States to add viral hepatitis therapies and viral
    load tests to their ADAP formularies. While Ryan White providers offer
    lifesaving care to co-infected clients, they also have the expertise
    and infrastructure to provide limited services to viral hepatitis mono-
    infected clients.
    Research
        Finally, research is needed to increase understanding of the
    pathogenesis of hepatitis B and C. Further research to improve
    hepatitis B and C treatments that are currently difficult to tolerate
    and have low ``cure'' rates are also needed. The development of
    clinical strategies to slow the progression of liver disease among
    persons living with chronic infection, especially to those who may not
    respond to current treatment must be addressed. With effective vaccines
    against hepatitis A and B, it is important to continue to work towards
    the development of a vaccine against hepatitis C infection. The Liver
    Disease Branch, located within the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH), has developed an Action Plan for Liver Disease Research.
    We request full funding for NIH to support the recommendations and
    action steps outlined in this Action Plan for Liver Disease Research.
        It is absolutely essential and urgent that we act aggressively to
    address the threat of viral hepatitis in the United States. In 2007
    alone, the CDC estimated that 43,000 Americans were newly infected with
    hepatitis B and 17,000 with hepatitis C. Unfortunately, it is believed
    that these estimates of hepatitis B and C infections are just the tip
    of the iceberg. Most people living with hepatitis B and over three-
    fourths of people living with hepatitis C do not know that they are
    infected. It is estimated that the baby boomer population currently
    accounts for 2 out of every 3 cases of chronic hepatitis C. It is also
    estimated that this epidemic will increase costs by billions of dollars
    to our private insurers and public systems of health such as Medicare
    and Medicaid, and account for billions lost due to decreased
    productivity from the millions of American workers suffering from
    chronic hepatitis B and C.
        As you continue to draft the fiscal year 2011 Labor, Health and
    Human Services, and Education, and Related Agencies Appropriations
    bill, we ask that you consider a generous increase for viral hepatitis
    prevention to counter several years of flat or inadequate growth in
    funding. A strong public health response is needed to meet the
    challenges of these costly infectious diseases. The viral hepatitis
    community welcomes the opportunity to work with you and your staff on
    this important issue.
                                     ______

                Prepared Statement of the Hepatitis B Foundation

        Mr. Chairman, my name is Dr. Timothy Block, and I am the President
    and Co-Founder of the Hepatitis B Foundation (HBF) and its research
    institute, the Institute for Hepatitis and Virus Research. I also serve
    as the president of the Pennsylvania Biotechnology Center and am a
    professor at Drexel University College of Medicine. My wife Joan, and
    I, and another couple, Paul and Janine Witte, from Pennsylvania started
    HBF almost 20 years ago to find a cure for this serious chronic liver
    disease and provide information and support to those affected.
        Thank you for giving HBF the opportunity to provide testimony to
    the subcommittee as you begin to consider funding priorities for fiscal
    year 2011. We are grateful to the members of this subcommittee for
    their interest and strong leadership for efforts to control and find
    cures for hepatitis B.
        Today, the HBF is the only national nonprofit organization solely
    dedicated to finding a cure and improving the lives of those affected
    by hepatitis B worldwide through research, education, and patient
    advocacy. Our scientists focus on drug discovery for hepatitis B and
    liver cancer, and early detection markers for liver cancer. HBF staff
    manages a comprehensive Web site which receives almost 1 million
    visitors each year, a national patient conference and outreach
    services. HBF public health professionals conduct research initiatives
    to advance our mission.
        The hepatitis B virus (HBV) is the world's major cause of liver
    cancer--and while other cancers are declining, liver cancer is the
    fastest growing in incidence in the United States. Without
    intervention, as many as 100 million worldwide will die from a HBV-
    related liver disease, most notably liver cancer. In the United States,
    up to 2 million Americans have been chronically infected and more than
    5,000 people die each year from complications due to HBV.
        HBV is 100 times more infectious than the HIV/AIDS virus. Yet,
    hepatitis B can be prevented with a safe and effective vaccine.
    Unfortunately, for those who are chronically infected with HBV, the
    vaccine is too late. There are, however, promising new treatments for
    HBV. We are getting close to solutions but lack of sustained support
    for public health measures and scientific research is threatening
    progress. The growing incidence of liver cancer, while most other
    cancer rates are on the decline, represents examples of serious
    shortcomings in our system. In the United States, 20,000 babies are
    born to mothers infected with HBV each year, and as many as 1,200
    newborns will be chronically infected with HBV. More needs to be done
    to prevent new infections.

                       INSTITUTE OF MEDICINE (IOM) REPORT

        In January of this year, the Institute of Medicine (IOM) issued a
    report titled Hepatitis and Liver Cancer: A National Strategy for
    Prevention and Control of Hepatitis B and C. This report outlined a
    national strategy for prevention and control of hepatitis B and C. The
    report concludes that the current approach to the prevention and
    control of viral hepatitis is not working and unless further action is
    taken thousands more Americans will die each year from liver cancer, or
    liver disease associated with these preventable diseases. In response
    to this monumental report, the Department of Health and Human Services
    Office of the Secretary has convened an inter-departmental task-force
    to address the public health challenge of viral hepatitis. HBF is very
    supportive of the Task Force and is hopeful that their recommendations
    will result in actions to address the chronic underfunding of viral
    hepatitis prevention programs within the Department.
        Mr. Chairman, as you know the two Federal agencies that are
    critical to the effort to help people concerned with hepatitis B are:
    the Centers for Disease Control and Prevention (CDC), and the National
    Institutes of Health CDC (NIH).

                                      CDC

        CDC's Division of Viral Hepatitis (DVH), the centerpiece of the
    Federal response to controlling, reducing, and preventing the suffering
    and deaths resulting from viral hepatitis, is chronically underfunded.
    DVH is included in the National Center for HIV/AIDS, Viral Hepatitis,
    STD, and TB Prevention at the CDC, and is responsible for the
    prevention and control of viral hepatitis. DVH is currently funded at
    $19.3 million, $6 million less than its funding level in fiscal year
    2003, which does not allow for the provision of core prevention
    services. The HBF joins the hepatitis community and urges a fiscal year
    2011 funding level for DVH of $50 million.
        The responsibility for addressing the problem of hepatitis should
    not lie solely with the DVH . In view of the preventable nature of
    these diseases, HBF feels that the National Center for Chronic Disease
    Prevention should also include a targeted effort focused on the
    prevention of chronic viral hepatitis which adversely impacts 5 million
    Americans. We urge that the subcommittee include $2 million in the
    National Center for Chronic Disease Prevention to initiate a focused
    program on chronic viral hepatitis.
        Furthermore, there are 400 million people chronically infected with
    hepatitis B worldwide, with more than 120 million of these individuals
    in China. While hepatitis B transmission requires direct exposure to
    infected blood, worldwide misinformation about the disease has fueled
    inappropriate discrimination against individuals with this vaccine-
    preventable bloodborne and treatable disease. HBF urges the
    subcommittee to instruct the CDC to initiate global programs to
    increase the rate of vaccination, reduce mother-child transmission, and
    promote educational programs to prevent the disease and to reduce
    discrimination targeted against individuals with the disease.

                                      NIH

        We depend upon the NIH to fund research that will lead to new and
    more effective interventions to treat people with hepatitis B and liver
    cancer. HBF joins with the Ad Hoc Group for Biomedical Research and
    requests a funding level of $35 billion for NIH in fiscal year 2011.
        We thank the subcommittee for their continued investment in NIH in
    fiscal year 2010. Sustaining progress in medical research is essential
    to the twin national priorities of smarter healthcare and economic
    revitalization. With additional investment, the Nation can seize the
    unique opportunity to build on the tremendous momentum emerging from
    the strategic investment in NIH made through the 2009 American Recovery
    and Reinvestment Act (ARRA). NIH invested those funds in a range of
    potentially revolutionary new avenues of research that will lead to new
    early screenings and new treatments for disease.
        In fiscal year 2009, NIH spent approximately $57 million on
    hepatitis B funding overall (ARRA and non-ARRA funds), and estimates
    that in fiscal year 2010 $54 million will be spent. An additional $40
    million per year could make transformational advances in research
    leading to better treatments for HBV. The HBF recommends that an
    additional $40 million be allocated for HBV research in fiscal year
    2010 and that overall NIH funding total $35 billion.
        The current leadership of the NIH has performed admirably with the
    limited resources they are provided; however, more is needed. While a
    number of cancers have achieved 5-year survival rates of over 80
    percent and the average 5-year survival rate for all cancers has
    increased from 50 percent in 1971 to 66 percent, significant challenges
    still remain for other types of cancers, particularly the most deadly
    forms of cancer. In fact, nearly half of the 562,340 cancer deaths in
    2009 were caused by eight forms of cancer with 5-year relative survival
    rates of less than 50 percent: ovary (45.5 percent), brain (35.0
    percent), myeloma (34.9 percent), stomach (24.7 percent), esophagus
    (15.8 percent), lung (15.2 percent), liver (11.7 percent), and pancreas
    (5.1 percent). It is no coincidence that cancers with significantly
    better 5-year survival rates, such as breast, prostate, colon,
    testicular, and chronic myelogenous leukemia, also have early detection
    tools, and in many cases, several effective treatment options thanks to
    research programs championed and supported by Congress. By contrast,
    research into the cancers with the lowest 5-year survival rates has
    been relatively underfunded, and as a result, these cancers have no
    early detection or treatment tools.
        HBF requests that the establishment of a targeted cancers program
    at the National Cancer Institute (NCI) for the high-mortality cancers.
    It should include a strategic plan for progress, an annual report from
    NCI to Congress, and a new grant program specifically focused on the
    deadly cancers. Additionally, HBF urges a stronger focus on liver
    cancer and urges the funding of a series of Specialized Programs of
    Research Excellence (SPOREs) focused on liver cancer. While SPOREs
    currently exist for every other major cancer, none currently exist that
    are focused on liver cancer.

                             SUMMARY AND CONCLUSION

        While the HBF recognizes the demands on our Nation's resources, we
    believe the ever-increasing health threats and expanding scientific
    opportunities continue to justify higher funding levels for the CDC's
    DVH and NIH.
        Significant progress has been made in developing better treatments
    and cures for the diseases that affect humankind due to your leadership
    and the leadership of your colleagues on this subcommittee. Significant
    progress has also similarly been made in the fight against hepatitis B.
        In conclusion, we specifically request the following for fiscal
    year 2011:
      --Fund the CDC's DVH at $50 million;
      --$2 million in the National Center for Chronic Disease Prevention to
            initiate a focused program on chronic viral hepatitis;
      --Initiate global programs at the CDC to increase the rate of
            vaccination, reduce mother-child transmission and promote
            educational programs to prevent the disease and to reduce
            discrimination targeted against individuals with the disease;
      --Provide $35 billion for NIH, including a $40 million increase per
            year for hepatitis B research;
      --Establish a targeted cancers program at the NCI; and
      --Fund a series of Specialized Programs of Research Excellence
            (SPOREs) focused on liver cancer at the NCI.
        HBF appreciates the opportunity to provide testimony to you on
    behalf of our constituents and yours.
        Thank you.
                                     ______

     Letter From the HIV Health and Human Services Planning Council of New
                                      York
                                                        April 16, 2010.
    Hon. Tom Harkin,
    Subcommittee on Labor, Health and Human Services, and Education, and
            Related Agencies, Washington, DC.
        Dear Senator Harkin: On behalf of the HIV Health and Human Services
    Planning Council of New York City, I write to urge you to increase
    funding for Ryan White Programs by $810.5 million more than the fiscal
    year 2010 appropriated levels in the fiscal year 2011 Labor, Health and
    Human Services, and Education, and Related Agencies; Transportation and
    Housing and Urban Development, and Related Agencies; and Financial
    Services and General Government appropriations bills.
        The HIV Health and Human Services Planning Council of New York is
    comprised of people living with HIV/AIDS, advocates, physicians, and
    service providers and prioritizes the allocation of Ryan White funds
    for treatment and care services for PLWHAs. Council Members are well
    versed in the challenges confronting people living with this illness
    and know that Ryan White HIV/AIDS Programs provide life-extending
    medical care, mental health and drug treatment, and support services to
    approximately 577,000 low-income, uninsured and underinsured
    individuals and families affected by HIV/AIDS each year. Your proposed
    fiscal year 2011 budget requests $2.33 billion for the Ryan White
    Program, but Planning Council members believe that more funding is
    needed in order to maintain a comprehensive system of care.
    Specifically, Planning Council members recommend the following
    increases:
      --Part A.--An increase of $225.9 million for grants to eligible
            metropolitan areas and transitional grant areas;
      --Part B.--An increase of $55.9 million for care grants to State,
            territories, and emerging communities;
      --Part B AIDS Drug Assistance Program.--An increase of $370.1 million
            to provide life-saving medications to more than 166,000
            individuals already enrolled in the program and the hundreds
            that are currently on waiting lists in 11 States;
      --Part C.--An increase of $131 million for early intervention
            services and capacity development grants;
      --Part D.--An increase of $7 million for women, infants, youth, and
            their families;
      --Part F/Dental.--An increase of $5.4 million for Dental School
            Reimbursement Programs and the Community-Based Dental
            Partnership Program; and
      --Part F/AETC.--An increase of $15.2 million for AIDS Education and
            Training Centers.
        My fellow Planning Council members join me in thanking you for your
    support and commitment to improving the lives of people living with
    HIV/AIDS and strongly encourage you to increase the amount of money to
    support treatment and care services.
                Sincerely yours,
                                       Charles W. Shorter, MSW,
                                                    Community Co-Chair.
                                     ______

               Prepared Statement of the HIV Medicine Association

        The HIV Medicine Association (HIVMA) of the Infectious Diseases
    Society of America represents more than 3,700 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. We work in communities across the country and around
    the globe as medical providers and researchers dedicated to the field
    of HIV medicine. We appreciate the fiscal challenges that Congress
    currently faces, but the state of the economy makes it imperative that
    our Nation have 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 the number of
    their new HIV patients continues to increase dramatically in some
    areas.
        Implementation of healthcare reform and the administration's plans
    for a National HIV/AIDS Strategy offer promise for making significant
    progress in reducing the impact of the domestic HIV epidemic. However,
    their success will depend on adequate investments in shoring up the
    frayed healthcare safety net, prevention and public health and research
    programs. The funding requests in our testimony largely reflect the
    consensus of the Federal AIDS Policy Partnership, 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 $1.13 billion in funding for
    the CDC's NCHHSTP with an increase of $878 million for HIV prevention
    and surveillance, an increase of $30.7 million for viral hepatitis and
    $76.3 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. 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.
    An infusion of HIV prevention funding is critical to restore and
    enhance HIV prevention programs by increasing support for cooperative
    agreements with State and local health departments; optimizing core
    surveillance cooperative agreements with health departments and
    expanding HIV testing in key healthcare and nonhealthcare venues by
    funding testing infrastructure and the purchase of approved testing
    devices, including rapid HIV tests and confirmatory testing and
    supporting linkage to care. 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.
        While we appreciate that the President proposed a $31 million
    increase for HIV prevention at the CDC, a much more robust investment
    is needed to significantly reduce the number of new HIV occurring
    annually in the United States. We strongly support the CDC initiative
    to integrate HIV screening into medical care as an important component
    of the prevention portfolio. 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 there is a growing body of evidence suggesting that
    treatment can reduce risk of HIV transmission. Furthermore through
    education, counseling and treatment, individuals who are aware that
    they have HIV are more likely to adopt behaviors to prevent
    transmission of 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. A significant investment of Federal resources is
    necessary to support State health departments, medical institutions,
    community health centers and other community based organizations with
    implementing these programs and for their full potential to be
    realized--particularly in light of steep State budget cuts.
        Identifying people with HIV earlier through routine HIV testing and
    linking them to HIV care saves lives and also 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.
        Finally, we also must increase support for science-based,
    comprehensive sex education programs. We are pleased that Congress took
    important steps in the fiscal year 2010 appropriations process to
    discontinue funding for unproven abstinence-only sex education programs
    and shift those funds to support comprehensive, age-appropriate sex
    education programs. We also support shifting administration of those
    funds to the Department of Health and Human Services' Office of
    Adolescent Health. However, we are concerned that by focusing the
    funding on teenage pregnancy prevention alone, and not including the
    equally important health issues of STIs and HIV, both the
    administration and Congress missed an opportunity to provide true,
    comprehensive sex education that promotes healthy behaviors and
    relationships for all young people, including lesbian, gay, bisexual,
    and transgender youth. We urge the subcommittee to adopt report
    language that broadens the scope of the new teen pregnancy prevention
    program to include an explicit focus on prevention of STDs including
    HIV.
    CDC--Tuberculosis
        Tuberculosis is the major cause of AIDS-related mortality
    worldwide. Two years ago, 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. Unfortunately,
    the Administration has proposed a cut of $1.2 million for domestic TB
    control. At a minimum, it is critical that the authorized funding level
    of $220.5 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
    HIVMA also supports for inclusion in fiscal year 2011 appropriations.
        Two years ago, Congress passed landmark legislation--the
    Comprehensive Tuberculosis Elimination Act of 2008--Public Law 110-873
    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 $220.5 million in funding authorized
    for fiscal year 2011 in this important law is appropriated for the CDC
    Division of TB Elimination. This represents an increase of $76.3
    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 $811 million in fiscal year 2011 with at least an increase of $131
    million for part C for a total Ryan White appropriation of $3.1
    billion. Ryan White Part C funds comprehensive HIV care and treatment--
    the medical services that are directly responsible for the dramatic
    decreases in AIDS-related mortality and morbidity over the last decade.
    While the patient caseload in part C programs has been rising, funding
    for part C has effectively decreased due to flat funding and funding
    cuts at the clinic level. Part C programs expect a continued increase
    in patients due to higher diagnosis rates and economic-related declines
    in insurance coverage. During this economic downturn people with HIV
    across the country are relying on part C comprehensive services more
    than ever. The HIV medical clinics funded through part C have been in
    dire need of increased funding for years, but new pressures are
    creating a crisis in communities across the country. An increase in
    funding is critical to prevent additional staffing and service cuts and
    ensure the public health of our communities.
        Minimal annual increases in Ryan White Part C allocations have
    lagged behind rapid cost increases in all aspects of healthcare
    delivery programs, leaving part C programs operating at a deficit while
    struggling to meet growing patient need. Part C programs provide
    comprehensive primary care to more than 240,000 HIV patients--which
    represents an increase of more than 30 percent in less than 10 years.
    Part C clinics are laying off staff, curtailing critical services such
    as laboratory monitoring, creating waitlists, and operating on a 4-day
    work week just to get by. For fiscal year 2011, HIVMA joins the Ryan
    White Medical Provider Coalition, The CAEAR Coalition, and the American
    Academy of HIV Medicine to request a $131 million funding increase for
    Part C programs. These funds are urgently needed to provide HIV care
    and treatment to Part C patients nationwide. 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 critical to meet the needs of HIV patients served by Part C
    programs around the country.
    Agency for Health Care Quality and Research (AHRQ)
        HIVMA strongly urges full funding of $1.95 million for the HIV
    Research Network (HIVRN), which represents the only significant HIV
    work being done at AHRQ. The HIVRN is a consortium of 18 HIV primary
    care sites co-funded by AHRQ and HRSA to evaluate healthcare
    utilization and clinical outcomes in HIV infected children, adolescents
    and adults in the United States. The Network analyzes and disseminates
    information on the delivery and outcomes of healthcare services to
    people with HIV infection. These data help to improve delivery and
    outcomes of HIV care in the United States and to identify and address
    disparities in HIV care that exist by race, gender, and HIV risk
    factor. The HIVRN is a unique source of information on the cost and
    cost-effectiveness of HIV care in the United States at a time when data
    on comparative cost and effectiveness of healthcare is particularly
    needed to inform health systems reform and the development and
    implementation of a National HIV/AIDS Strategy. The HHS budget retained
    the HRSA share of HIVRN funding ($.4 million), but inexplicably zeroed
    out the AHRQ funding for the program, without any policy rationale for
    eliminating it.
    National Institutes of Health (NIH)--Office of AIDS Research
        HIVMA strongly supports an increase of at least $4 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.
        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 support these programs. We must seize 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.
                                     ______

    Prepared Statement of the Hepatitis Outbreaks National Organization for
                              Reform (HONOReform)

        Mr. Chairman and members of the subcommittee: As President and Co-
    Founder 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 2008 when an outbreak that
    potentially exposed more than 63,000 patients to hepatitis C occurred
    in Las Vegas, Nevada. 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, cannot
    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, which is
    currently being piloted in New York and Nevada, 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.''
        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, and HHS to help prevent
    future hepatitis and HIV outbreaks through the following two fiscal
    year 2011 appropriations requests:
    Supporting CDC's Division of Healthcare Quality and Promotion
        HONOReform requests $26 million for CDC Division of Healthcare
    Quality and Promotion to address outbreaks and promote innovative ways
    to adhere to injection safety and infection control guidelines.
        The CDC provides national leadership in surveillance, outbreak
    investigations, laboratory research, and prevention of healthcare-
    associated infections. The transition of healthcare delivery from
    primarily acute care hospitals to other healthcare settings (e.g., home
    care, ambulatory care, free-standing specialty care sites, long-term
    care) requires that common principles of infection control practice be
    applied to the spectrum of healthcare delivery settings. In light of
    the recent healthcare-associated transmissions of HCV in Denver,
    Colorado, Las Vegas, Nebraska, North Carolina, New York City, Long
    Island, and Grand Rapids, Michigan, 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.
    Provider Education and Awareness ($5 million)
        Funds to develop safe practice tools for additional inpatient and
    outpatient healthcare settings in conjunction with key partners and
    stakeholders. This will include training tools to be used by
    professional organizations and accreditation and licensing groups to
    increase adherence to recommendations. Funds will assist in
    dissemination and use of tools to aid in implementing State HAI Action
    Plans. Funds to expand the One & Only injection safety education and
    awareness campaign, provide educational materials to all 50 States
    through State health departments' HAI coordinators implement a national
    media launch to promote awareness of the One & Only Campaign in
    collaboration with the Safe Injection Practices Coalition and State
    health departments; and evaluate the impact of the Campaign. Funds to
    expand implementation of CMS surveys of injection safety practices in
    ambulatory surgical centers to all outpatient settings.
    Engineering and Innovation ($7 Million)
        Funds to support the CDC in promoting private-sector and academic
    healthcare solutions to injection safety and infection control
    problems. This funding will enable the CDC to engage with industry and
    academia through extramural grant mechanisms to:
      --Examine current technologies and practices that eliminate the risk
            of human error through unsafe injection practices;
      --Identify and develop fast tracked safety engineered-solutions for
            next generation products; and
      --Demonstrate effectiveness of new technology to support inclusion in
            Federal guidelines.
    Detection, Tracking, and Response ($14 million)
        Funds to expand augmentation of CMS survey capacity in outpatient
    settings to strengthen State capacity to detect infections that
    indicate errors in injection practices. These funds will enable the
    CDC, in collaboration with CMS, to expand surveillance in 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 to assist State and local health
    departments implement State HAI Action Plans, including detection and
    tracking in order to investigate outbreaks of healthcare-associated
    infections and other adverse events related to injection safety.
        Funds to enable the CDC to provide assistance and respond to
    outbreaks resulting from the re-use of syringes as requested by health
    departments and health systems. Funds to the CDC to develop CDC
    Toolkits of best practices for patient notifications and
    postnotification support and best practices for investigations and
    detecting clusters of outbreaks, to be used by State and local health
    departments and healthcare systems.
    Encouraging HHS To Focus on HAIs in the Outpatient Setting
        HONOReform requests $1 million for the Department of Health and
    Human Services (HHS) to expand its current focus for reducing HAIs from
    hospitals to outpatient settings with the development of an action plan
    to reduce HAIs in outpatient settings with a specific focus on
    injection safety. HONOReform is 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 2 years, more than 150,000
    patients in the United States have received ominous letters from public
    health officials warning of possible exposure to deadly diseases like
    hepatitis and HIV because their providers failed to follow fundamental
    safety measures.
        The increased frequency of such outbreaks was highlighted in the
    February 2010 article, ``U.S. Outbreak Investigations Highlight the
    Need for Safe Injection Practices and Basic Infection Control'',
    published in Clinics in Liver Disease. The article attributed these
    outbreaks to lapses in basic infection control (i.e., syringe reuse and
    misuse of single dose and multidose vials).
    HAIs in the Outpatient Setting ($1 million)
        Funds to expand HHS' current focus for reducing healthcare-
    associated infections (HAIs) from hospitals to outpatient settings with
    the development and implementation of an action plan to reduce HAIs in
    unlicensed outpatient settings and Health Resources and Services
    Administration Community Care Centers including a specific focus on
    injection safety. Funds to increase education, certifications, and
    continuing education of medical, nursing, and allied health
    professionals, including State-based certification, related to
    injection safety.
                                     ______

      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 $600 million in fiscal year 2011 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 increases provided for
    many title VII and title VIII programs in the fiscal year 2010 Omnibus
    Appropriations bill (Public Law 111-117). These investments are crucial
    to addressing the existing and looming shortages of healthcare
    professionals in this country and are key to ensuring the Nation's
    healthcare professionals are able to care for the medically
    underserved. The Patient Protection and Affordable Care Act (Public Law
    111-148) updated and restructured the existing title VII and title VIII
    programs to improve their efficiency, effectiveness, and
    accountability, and reauthorized them at funding levels reflective of
    the health workforce needs of the Nation. In addition to reauthorizing
    the existing health professions programs, the legislation authorizes
    several new programs and initiatives under titles VII and VIII designed
    to mitigate health workforce challenges and expand the scope of the
    programs to additional fields. HPNEC encourages an investment in these
    new programs that supplements the support for the core title VII and
    title VIII programs. These investments will be critical to ensuring
    that the healthcare workforce can accomplish the goals of healthcare
    reform.
        We are grateful to President Obama for highlighting the need to
    strengthen the health professions workforce as a national priority;
    however, significant strides must still be made to ensure that all
    Americans have access to the health professionals they need. According
    to HRSA, an additional 31,000 health practitioners are needed to
    alleviate existing 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 to ensure that the title VII and title VIII programs
    are able to continue strengthening the country's safety net for the
    healthcare needs of the medically underserved.
        The existing title VII and title VIII programs can be considered in
    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 make funds available to
            eligible students from disadvantaged backgrounds who are
            enrolled as full-time health professions students.
      --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, while
            the Dental Public Health Residency programs are vital to the
            Nation's dental public health infrastructure. 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. And finally, the primary care cluster enhances
            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 older adults. 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 National Sample Survey of
            Registered Nurses, the Nation's most extensive and
            comprehensive source of statistics on registered nurses.
      --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 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 77,395 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 tens of thousands of 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. 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 students from disadvantaged backgrounds 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
            financially 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 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. While HPNEC members are keenly aware
    of the fiscal pressures facing the subcommittee, we respectfully urge
    support for funding of at least $600 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 also encourage an investment in the new
    programs and responsibilities authorized in the Patient Protection and
    Affordable Care Act to supplement the investment in the existing core
    programs. We greatly appreciate the support of the subcommittee and
    look forward to working with Members of Congress to reinvest in the
    health professions programs in fiscal year 2011 and into the future.
                                     ______

                 Prepared Statement of the Home Safety Council

                                  INTRODUCTION

        Chairman Harkin, Vice Chairman Cochran, and members of the
    subcommittee, thank you for the opportunity to submit testimony on the
    fiscal year 2011 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 officer and director of
    public policy for the Home Safety Council (HSC) which is located in
    Washington, DC.

                         ABOUT THE HOME SAFETY COUNCIL

        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 $20 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 HEALTH CARE 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.
      --Nearly 30 million people are treated for injuries in U.S. emergency
            departments each year. This is an average of 55 people each
            minute.
      --In a single year, injury and violence will cost the United States
            $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 two Senate Resolutions in 2008 and 2009 recognizing National
    Falls Prevention Awareness Day each September. For the good intentions
    of Congress to bear fruit, an appropriation of $20 million is needed
    for fiscal year 2011 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 $20
    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, thank you for the opportunity to share our fiscal
    year 2011 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 of the United States

        On behalf of The Humane Society of the United States (HSUS) and the
    Humane Society Legislative Fund, and our joint membership of more than
    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 2011.

                      BREEDING OF CHIMPANZEES FOR RESEARCH

        The HSUS requests that no Federal funding be appropriated for the
    breeding of chimpanzees for research. The basis of our request can be
    found below.
      --The National Center for Research Resources (NCRR) of the National
            Institutes of Health (NIH), responsible for the oversight and
            maintenance of federally owned chimpanzees, placed a moratorium
            on funding the breeding of federally owned and supported
            chimpanzees in 1995, primarily due to the excessive costs of
            lifetime care of chimpanzees in laboratory settings. NCRR made
            this moratorium permanent in 2007. As a result, no federally
            owned chimpanzees should have given birth or sired infants
            since 1995 and no federally owned chimpanzees should have a
            date of birth later than 1995. We have discovered, however,
            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.
      --According to records obtained from the New Iberia Research Center
            (NIRC), 42 federally owned females and 9 federally owned males
            have been used for breeding since the 1995 moratorium was put
            into place. Furthermore, at least 29 infants were born to a
            federally owned mother and/or federally owned father since 1995
            and 27 federally owned chimpanzees have a date of birth after
            1995.
      --There is evidence that chimpanzees being bred by the NIRC--through
            their contract with the National Institute of Allergy and
            Infectious Diseases (NIAID)--are owned or supported by NCRR,
            and as a result, in violation of NCRR's breeding moratorium.
      --The cost of maintaining chimpanzees in laboratories is exorbitant,
            totaling up to $28 million each year for the current population
            of approximately 800 federally owned or supported chimpanzees
            (up to $67 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.
    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 800 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. 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 60 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 2011.
    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 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 standards are often not being
    met. Inspection reports for other federally funded chimpanzee
    facilities have reported violations of the Animal Welfare Act in recent
    years, including the death of a chimpanzee during improper transport,
    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/Mikkelsen,
    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 committee report
    language:

        ``The Committee directs that no funds provided in this Act be used
    to support the breeding of chimpanzees for research.''

        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 2011. 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.

     HIGH THROUGHPUT SCREENING, TOXICITY PATHWAY PROFILING, AND BIOLOGICAL
                           INTERPRETATION OF FINDINGS

    NIH--Office of the Director
        In 2007, the National Research Council published its report titled
    ``Toxicity Testing in the 21st Century: A Vision and a Strategy.'' This
    report catalyzed collaborative efforts across the research community to
    focus on developing new, advanced molecular screening methods for use
    in assessing potential adverse health effects of environmental agents.
    It is widely recognized that the rapid emergence of omics technologies
    and other advanced technologies offers great promise to transform
    toxicology from a discipline largely based on observational outcomes
    from animal tests as the basis for safety determinations to a
    discipline that uses knowledge of biological pathways and molecular
    modes of action to predict hazards and potential risks.
        In 2008, NIH, NIEHS, and EPA signed a memorandum of understanding
    \6\ to collaborate with each other to identify and/or develop high
    throughput screening assays that investigate ``toxicity pathways'' that
    contribute to a variety of adverse health outcomes (e.g., from acute
    oral toxicity to long-term effects like cancer). In addition, the MOU
    recognized the necessity for these Federal research organizations to
    work with ``acknowledged experts in different disciplines in the
    international scientific community.'' Much progress has been made, but
    there is still a significant amount of research, development and
    translational science needed to bring this vision forward to where it
    can be used with confidence for safety determinations by regulatory
    programs in the Government and product stewardship programs in the
    private sector. In particular, there is a growing need to support
    research to develop the key science-based interpretation tools which
    will accelerate using 21st century approaches for predictive risk
    analysis. We believe the Office of the Director at NIH can play a
    leadership role for the entire U.S. Government by funding both
    extramural and intramural research.
    ---------------------------------------------------------------------------
        \6\ http://www.genome.gov/pages/newsroom/currentnewsreleases/
    ntpncgcepamou121307finalv2.pdf.
    ---------------------------------------------------------------------------
        We respectfully request the following committee report language:

        ``The Committee supports the implementation of the National
    Research Council's report `Toxicity Testing in the 21st Century: A
    Vision and a Strategy' to create a new paradigm for risk assessment
    based on use of advanced molecular biological methods in lieu of animal
    toxicity tests and urges the National Institutes of Health to play a
    leading role by funding relevant intramural and extramural research
    projects. Current activities at the NIH Chemical Genomics Center,
    National Institute of Environmental Health Sciences and the
    Environmental Protection Agency show considerable potential and the NIH
    Director should explore opportunities to augment this effort by
    identifying possible additional resources that could be directed to key
    extramural research projects.''
                                     ______

      Prepared Statement of the Harlem United Community AIDS Center, Inc.

    Harlem United Overview
        Harlem United Community AIDS Center, Inc. (Harlem United) is a
    community-based, nonprofit organization providing comprehensive,
    integrated care to individuals and families living with HIV/AIDS in
    Upper Manhattan area of New York City and its nearby boroughs.
        Harlem United provides a full range of medical, social, and
    supportive services to people living with HIV/AIDS whose diagnoses are
    often complicated by addiction, mental illness, and homelessness.
    Harlem United utilizes a comprehensive model of care that includes HIV
    testing; treatment and education; primary medical care; substance use
    counseling; mental health services; and an array of expressive
    therapies. Each year we touch the lives of more than 6,000 people
    through our services and myriad locations, including two AIDS Adult Day
    Health Care centers. At these centers, patients receive medication
    management, healthcare monitoring, case management, substance abuse
    services, nutritional services, and health education. We are proud that
    we deliver evidence-based, outcome-driven, comprehensive, medically
    endorsed care in a cost-effective and supportive setting.
        Harlem United is very concerned about increasing HIV incidence
    among men who have sex with men (MSM) of all races and ethnicities.
    Harlem United's Black Men's Initiative endeavors to reduce rates of HIV
    infection and transmission of sexually transmitted infections (STIs)
    among young Black and Latino MSM in New York City. Our Education and
    Training Department works with populations and individuals at increased
    risk for HIV infection, such as MSM, to increase knowledge and skills
    to prevent HIV transmission and improve HIV-related health outcomes.
    Our programs include evidence-based HIV prevention interventions,
    comprehensive risk-reduction counseling, confidential HIV rapid testing
    and STI screenings, primary care, mental health, and supportive housing
    services many of which specialize in mobilizing effective responses for
    Black and Latino MSM.
    HIV/AIDS and MSM
        MSM account for nearly half of the more than 1 million people
    living with HIV in the United States and half of all new HIV infections
    in the United States each year. While the Centers for Disease Control
    and Prevention (CDC) estimates that MSM account for just 4 percent of
    the U.S. male population aged 13 and older, the rate of new HIV
    diagnoses among MSM in the United States is more than 44 times that of
    other men and more than 40 times HIV diagnoses among women. MSM is the
    only risk group in the United States in which new HIV infections are
    increasing.\1\
    ---------------------------------------------------------------------------
        \1\ ``CDC Fact Sheet: HIV and AIDS among Gay and Bisexual Men,''
    Centers for Disease Control and Prevention (March 2010). Available at
    http://www.cdc.gov/nchhstp/newsroom/docs/FastFacts-MSM-
    FINAL508COMP.pdf.
    ---------------------------------------------------------------------------
        As the CDC's fiscal year 2011 Congressional Justification noted,
    MSM of all races/ethnicities are at increased risk, but substantial
    racial/ethnic disparities do exist among MSM, with Black and Hispanic
    MSM bearing the greatest burden of the disease. The most alarming HIV
    infection increases are occurring among MSM ages 13-29 and 45 and
    older.\2\ Despite having lower infection rates than older MSM, younger
    MSM are more likely to have an undiagnosed HIV infection. HIV infection
    among MSM is facilitated by a number of factors including STIs,
    substance use, and community fatigue with HIV prevention messages. CDC
    should work with community leaders to inform methodology for
    communicating about HIV burden in MSM communities that encourages,
    rather than discourages, greater adoption of effective HIV prevention
    strategies.
    ---------------------------------------------------------------------------
        \2\ ``Fiscal Year 2011 Centers for Disease Control and Prevention
    Justification of Estimates for Appropriations Committees,'' Department
    of Health and Human Services, 74. Available at http://cdc.gov/fmo/
    topic/Budget%20Information/appropriations_budget_form_pdf/
    FY2011_CDC_CJ_Final.pdf.
    ---------------------------------------------------------------------------
        According to the CDC, recent increases in syphilis have largely
    been seen among MSM and syphilis is associated with a two-to-five fold
    increased risk of HIV. Higher rates of gonorrhea, which also
    facilitates HIV acquisition and transmission, have been documented
    among MSM who are HIV-infected. Thus, more needs to be done to address
    STIs and HIV for MSM given their elevated risk for infection. CDC data
    published in 2005 suggest that as few as 1 in 5 MSM received individual
    or group-level HIV prevention interventions in the prior year.\3\
    ---------------------------------------------------------------------------
        \3\ ``Fiscal Year 2011 Centers for Disease Control and Prevention
    Justification of Estimates for Appropriations Committees,'' 74.
    ---------------------------------------------------------------------------
    CDC Program for MSM
        In the fiscal year 2011 budget, the President has requested $27
    million for CDC to undertake targeted HIV and STI prevention efforts
    for MSM. We understand this initiative will build on an effort begun in
    2008, when the CDC provided $4 million in supplemental funding to 51
    health departments to re-assess and strengthen their plans to address
    HIV among MSM in their jurisdictions. Harlem United is pleased that the
    CDC will expand this focused initiative to prevent HIV through holistic
    and integrated approaches to protect the health of gay, bisexual, and
    other MSM. We applaud this multiyear effort to prevent new HIV
    infections, reduce the acquisition of STIs, and address substance
    abuse. Harlem United hopes that additional resources will be directed
    to this effort as they are identified.
        Studies show that the majority of individuals who are aware of
    their HIV-positive diagnosis proactively make changes to their behavior
    to prevent further spread of HIV. Increased access to routine HIV
    testing, irrespective of risk, is a key policy priority for Harlem
    United; as such, we hope that the expanded MSM effort will complement
    the 2010 HIV Expanded Testing Initiative focused on MSM.
        We anticipate that the additional resources requested for fiscal
    year 2011 by the President will expand HIV testing and prevention
    services to more MSM who need them, improve monitoring for co-
    infections among MSM and HIV-infected persons, and support the
    development and refinement of intervention services specifically for
    MSM. Based upon the racial and ethnic burden of HIV/AIDS among Hispanic
    and Black MSM and Harlem United's strong commitment to serve this
    population, we are pleased that the CDC efforts will be focused on
    these populations.
        Social determinants are an essential component to determining HIV
    vulnerability among MSM. Effective HIV prevention strategies must be
    mobilized simultaneously on an individual and community-level to
    successfully reduce HIV vulnerability and infections. We encourage CDC
    to utilize these new resources to promulgate a full continuum of HIV
    prevention interventions which provide MSM with an array of strategies
    that will best enable them to protect their sexual in the various ways
    they might experience HIV-risk in their lives. Harlem United maintains
    that HIV prevention among MSM should include the following initiatives:
      --Increase capacity among existing community-based organizations
            whose primary focus is HIV prevention among MSM, particularly
            MSM of color, or have programs which focus primarily on HIV
            prevention among MSM;
      --Targeted social and sexual network based HIV testing approaches,
            inclusive of Internet-based outreach;
      --Peer-driven linkage to care initiatives that strive to connect
            newly diagnosed and lost-to-care HIV-positive MSM to high-
            quality and affordable healthcare; and
      --Culturally competent social marketing campaigns which reach beyond
            HIV testing and condom use to educate MSM communities about
            strategies to protect themselves from HIV reflective of
            existing community risk behaviors.
        Finally, given the alarming disparity of HIV and syphilis incidence
    among MSM, we also urge the CDC to assemble an MSM advisory group that
    would provide guidance to decisionmaking officials in the Division of
    HIV/AIDS Prevention on barriers to implementation and best practices to
    be replicated. Further, this advisory group would work with CDC to
    integrate HIV and STI prevention and screening programs in clinical and
    community-based settings.
        We urge Congress to fulfill the President's request of $27 million
    for the CDC's MSM HIV and STI program and ensure that available
    resources reach communities and populations who need them most.
    Conclusion
        We very much appreciate the opportunity to provide written
    testimony in support of our Nation's efforts to prevent HIV/AIDS among
    gay, bisexual, and other MSM at the CDC. While President Obama's budget
    certainly reflects his commitment to the domestic fight against HIV/
    AIDS, any increase in funding Congress provides to the CDC program
    aimed at preventing HIV/AIDS and STIs among MSM would be greatly
    appreciated and would help us further our efforts to reverse the ever
    growing HIV epidemic in Harlem, other New York neighborhoods, and
    across the Nation.
        Harlem United is a member of the Federal AIDS Policy Partnership
    and joins in the coalition's funding requests with respect to domestic
    HIV/AIDS prevention funding and its call for increased funding for the
    Ryan White Care Act programs.
        Harlem United stands ready to be a resource for the subcommittee
    and its staff with respect to HIV/AIDS prevention, the care and
    treatment of individuals living with HIV/AIDS, and the provision of
    supportive services for individuals living with HIV/AIDS and the
    homeless.
                                     ______

       Prepared Statement of the International Foundation for Functional
                           Gastrointestinal Disorders

        Thank you for the opportunity to present the views of the
    International Foundation for Functional Gastrointestinal Disorders
    (IFFGD) regarding the importance of functional gastrointestinal (GI)
    and motility disorders research.
        Established in 1991, the IFFGD is a patient-driven nonprofit
    organization dedicated to assisting individuals affected by functional
    GI disorders, and providing education and support for patients,
    healthcare providers, and the public at large. The IFFGD also works to
    advance critical research on functional GI and motility disorders, in
    order to provide patients with better treatment options, and to
    eventually find a cure. The IFFGD has worked closely with NIH on a
    number of priorities, including the NIH State-of-the-Science Conference
    on the Prevention of Fecal and Urinary Incontinence in Adults through
    NIDDK, the National Institute of Child Health and Human Development
    (NICHD), and the Office of Medical Applications of Research (OMAR). I
    have served on the National Commission on Digestive Diseases (NCDD),
    which released a long-range road map for digestive disease research in
    2009, entitled Opportunities and Challenges in Digestive Diseases
    Research: Recommendations of the National Commission on Digestive
    Diseases.
        The need for increased research, more effective and efficient
    treatments, and the hope for discovering a cure for functional GI and
    motility disorders are close to my heart. My own personal experiences
    as someone suffering from functional GI and motility disorders
    motivated me to establish the IFFGD 19 years ago. I was shocked to
    discover that despite the high prevalence of these conditions among all
    demographic groups worldwide, such an appalling lack of dedicated
    research existed. This lack of research translates into a dearth of
    diagnostic tools, treatments, and patient supports. Even more shocking
    is the lack of awareness among both the medical community and the
    general public, leading to significant delays in diagnosis, frequent
    misdiagnosis, and inappropriate treatments including unnecessary
    medication and surgery. It is unacceptable for patients to suffer
    unnecessarily from the severe, painful, life-altering symptoms of
    functional GI and motility disorders due to a lack of awareness and
    education.
        The majority of functional GI disorders have no cure and treatment
    options are limited. Although progress has been made, the medical
    community still does not completely understand the mechanisms of the
    underlying conditions. Without a known cause or cure, patients
    suffering from functional GI disorders face a lifetime of chronic
    disease management, learning to adapt to intolerable, disruptive
    symptoms. The medical and indirect costs associated with these diseases
    are enormous; estimates range from $25--$30 billion annually. Economic
    costs spill over into the workplace, and are reflected in work
    absenteeism and lost productivity. Furthermore, the emotional toll of
    these conditions affects not only the individual but also the family.
    Functional GI disorders do not discriminate, effecting all ages, races
    and ethnicities, and genders. These diseases account for significant
    lost opportunities for the individual as well as for society.
    Irritable Bowel Syndrome (IBS)
        IBS, one of the most common functional GI disorder, strikes all
    demographic groups. It affects 30 to 45 million Americans,
    conservatively at least one out of every 10 people. Between 9 to 23
    percent of the worldwide population suffers from IBS, resulting in
    significant human suffering and disability. IBS is a chronic disease is
    characterized by a group of symptoms that may vary from person to
    person, but typically include abdominal pain and discomfort associated
    with a change in bowel pattern, such as diarrhea and/or constipation.
    As a ``functional disorder'', IBS affects the way the muscles and
    nerves work, but the bowel does not appear to be damaged on medical
    tests. Without a definitive diagnostic test, many cases of IBS go
    undiagnosed or misdiagnosed for years. It is not uncommon for IBS
    suffers to have unnecessary surgery, medication, and medical devices
    before receiving a proper diagnosis. Even after IBS is identified,
    treatment options are sorely lacking, and vary widely from patient to
    patient. What is known is that IBS requires a multidisciplinary
    approach to 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. Stigma surrounding bowel habits may
    act as barrier to treatment, as patients are not comfortable discussing
    their symptoms with doctors. Because IBS symptoms are relatively common
    and not life-threatening, many people dismiss their symptoms or attempt
    to self-medicate using over-the-counter medications. In order to
    overcome these barriers to treatment, ensure more timely and accurate
    diagnosis, and reduce costly unnecessary procedures, educational
    outreach to physicians and the general public remain key.
    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 of 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 of 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 fund the NIH at level of $35 billion for
    fiscal year 2011, an increase of 12 percent over fiscal year 2010. This
    funding level will help preserve the initial investment in healthcare
    innovation established by the American Recovery and Reinvestment Act of
    2009. Strengthening and preserving our Nation's biomedical research
    enterprise fosters economic growth, and supports innovations that
    enhance the health and well-being of the American people.
        Concurrent with overall NIH funding, the IFFGD supports growth of
    research activities on functional GI and motility disorders,
    particularly through NIDDK and the Office of Research on Women's Health
    (ORWH). Increased support for NIDDK and ORWH will facilitate necessary
    expansion of the research portfolio on functional GI and motility
    disorders necessary to grow the medical knowledge base and improve
    treatment. Such support would also expedite the implementation of
    recommendations from the National Commission on Digestive Diseases.
        Following years of near level-funding at NIH, research
    opportunities have been negatively impacted across all NIH Institutes
    and Centers, including NIDDK. With the expiration of funding from the
    American Recovery and Reinvestment Act of 2009, medical researchers run
    the risk of ``falling off a cliff'', stalling, if not losing promising
    research from that 2 year period. For this reason, the IFFGD encouraged
    support for initiatives such as the Cures Acceleration Network (CAN),
    authorized in the Patient Protection and Affordable Coverage Act. The
    IFFGD urges the Subcommittee to show strong leadership in pursuing a
    substantial funding increase for CAN through the fiscal year 2011
    appropriations process.
        Thank you for the opportunity to present the views of the
    functional GI disorders community.
                                     ______

         Letter From the Industrial Minerals Association--North America
                                                        April 12, 2010.
    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 Chairman Harkin and Ranking Member Cochran: I write to request
    additional appropriations for the Department of Labor's Mine Safety and
    Health Administration (MSHA). Specifically the Industrial Minerals
    Association--North America (IMA-NA) requests a one-time appropriation
    of $3.6 million to improve MSHA's communication capabilities,
    specifically videoconferencing capabilities, and $1.7 million annually
    thereafter to maintain and operate these enhanced communications
    capabilities. This funding level is adequate to establish enhanced
    communications capabilities at 20 sites nationally and capable of
    reaching directly fully 80 percent of MSHA's approximately 2,500
    employees.
        It generally is recognized that mine inspectors need to stay
    abreast of the latest developments in mine safety, be informed of
    changes in regulatory standards and interpretations, be able to learn
    from mine incidents from various parts of the country, and feel a sense
    of connectedness with their headquarters in Arlington, Virginia. In
    light of recent tragic events in West Virginia, these constituent
    components of MSHA's mission take on added poignancy. To accomplish
    these important tasks, MSHA needs a state-of-the-art communications
    system. MSHA should be able to instantly and effectively communicate
    with, train, and retrain its inspectors over distance.
        You may be aware that the Department of Labor's Office of Inspector
    General recently released an audit report regarding ``Journeyman Mine
    Inspectors Do Not Receive Mandated Periodic Retraining.'' Report Number
    05-10-001-06-001 (http://www.oig.dol.gov/public/reports/oa/2010/05-10-
    001-06-001.pdf). The additional appropriations requested for enhanced
    communications capabilities could go a long way toward addressing
    issues raised in this report.
        The communications systems relied upon by MSHA are antiquated and
    ineffective. MSHA is relying on dated communications and IT
    infrastructure that is decades behind the capabilities of those they
    regulate. They also are substandard when compared to those of the
    National Institute for Occupational Safety and Health, the mine safety
    and health research agency that supports MSHA's mission. This is not
    acceptable.
        Similarly, MSHA's ability to perform meaningful stakeholder
    education and outreach demands state-of-the-art communications systems.
    Adequately trained inspectors and consistency of enforcement are
    necessary components of MSHA's mission and the lack of appropriate
    information technology infrastructure frustrates their full
    implementation. Less than full implementation frustrates stakeholders.
    For instance, the enhanced communications capability requested could
    allow a mine operator at a locally convenient site to consult with MSHA
    officials at a distant site. Similarly, the enhanced communications
    capabilities could be used broadly, permitting MSHA to educate
    stakeholders and perform industry outreach by district, regionally and
    nationally, benefiting mine operators and miners alike.
        IMA-NA respectfully requests your support for additional funding to
    improve MSHA's communication capabilities, specifically
    videoconferencing capabilities.
        The IMA-NA is a trade association organized to advance the
    interests of North American companies that mine or process industrial
    minerals. These minerals are used as feedstocks for the manufacturing
    and agricultural industries and are used to produce essential products.
    Industrial minerals are critical to the manufacture of glass, ceramics,
    paper, plastics, rubber, insulation, pharmaceuticals, and cosmetics.
    They also are used to make foundry cores and molds used for metal
    castings, and in paints, filtration, metallurgical applications,
    refractory products and specialty fillers. The IMA-NA membership
    includes producers of ball clay, barite, bentonite, borates, calcium
    carbonate, diatomite, feldspar, industrial sand, magnesia, mica, soda
    ash (trona), talc, wollastonite and other minerals. IMA-NA's membership
    also includes many of the suppliers to the industrial minerals
    industry, including equipment manufacturers, railroads and trucking
    companies, and consultants. Finally, the following hyperlink will
    direct you to our Web site, which provides additional information on
    this important mining sector (http://www.ima-na.org).
        Thank you for your timely consideration of this request.
                Sincerely,
                                                 Mark G. Ellis,
                                                             President.
                                     ______

         Prepared Statement of the Interstate Mining Compact Commission

        We are writing in support of the fiscal year 2011 budget request
    for the Mine Safety and Health Administration (MSHA), which is part of
    the U.S. Department of Labor. In particular, we urge the subcommittee
    to support a full appropriation for grants to States for safety and
    health training of our Nation's miners pursuant to section 503(a) of
    the Mine Safety and Health Act of 1977. MSHA's budget request for state
    grants is $8.941 million. This is the same amount that has been
    appropriated for State training grants by Congress over the past 2
    fiscal years and, as such, does not fully consider inflationary and
    programmatic increases being experienced by the States. We therefore
    urge the subcommittee to restore funding to the statutorily authorized
    level of $10 million for State grants so that States are able to meet
    the training needs of miners and to fully and effectively carry out
    State responsibilities under section 503(a) of the act.
        The Interstate Mining Compact Commission (IMCC) is a multi-state
    governmental organization that represents the natural resource,
    environmental protection, and mine safety and health interests of its
    24 member States. The States are represented by their Governors who
    serve as commissioners.
        IMCC's member States are concerned that without full funding of the
    State grants program, the federally required training for miners
    employed throughout the United States will suffer. States are
    struggling to maintain efficient and effective miner training and
    certification programs in spite of increased numbers of trainees and
    the incremental costs associated therewith. State grants have flattened
    out over the past several years and are not keeping place with
    inflationary impacts or increased demands for training. The situation
    is of particular concern given the enhanced, additional training
    requirements growing out of the recently enacted MINER Act and MSHA's
    implementing regulations.
        As you consider our request to increase MSHA's budget for State
    training grants, please keep in mind that the States play a
    particularly critical role in providing special assistance to small
    mine operators (those coal mine operators who employ 50 or fewer miners
    or 20 or fewer miners in the metal/nonmetal area) in meeting their
    required training needs.
        We appreciate the opportunity to submit our views on the MSHA
    budget request as part of the overall Department of Labor budget.
    Please feel free to contact us for additional information or to answer
    any questions you may have.
                                     ______

           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 2011 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 and its
    prevalence appears to be is increasing significantly. At any one time
    there are over 100,000 myeloma patients undergoing treatment for their
    disease in the United States. In 2009, 20,580 Americans were diagnosed
    with myeloma and 10,580 lost their battle with this disease.
        Although the incidence of many cancers is decreasing, myeloma cases
    are increasing in incidence. Once almost exclusively a disease of the
    elderly, myeloma is now being found in increasing numbers in people
    under the age of 65, and it is not uncommon for patients to be
    diagnosed in their 30s. IMF-funded research suggests that much of this
    increase is being caused by environmental toxins. To give just one
    example supporting this hypothesis, relatively recent published reports
    in the peer-reviewed literature have identified a disproportionate
    incidence of myeloma among clean-up and rescue workers at the 9/11
    World Trade Center site.
        In recent years significant gains have been made, extending myeloma
    patients' lives and improving their quality of life. Furthermore,
    progress begun in myeloma is already helping patients with other blood
    cancers and even solid tumors. Now it's important to maintain that
    momentum.
      --There is no cure for myeloma
      --Remissions are not permanent
      --Additional treatment options are essential
        At the same time, even while they live with the disease, myeloma
    patients can suffer debilitating fractures and other bone disorders,
    severe side effects of certain treatments, and other problems that
    profoundly affect their quality of life, and significantly impact the
    cost of their healthcare.
    Sustain and Seize Cancer Research Opportunities
        Myeloma research is producing extraordinary breakthroughs--leading
    to new therapies that translate into longer survival and improved
    quality of life for myeloma patients and potentially those with other
    forms of cancer as well. Myeloma was once considered a death sentence
    with limited options for treatment, but today 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.
    Our Nation has benefited immensely from past Federal investment in
    biomedical research at the National Institutes of Health (NIH) and the
    IMF advocates $33.349 billion for NIH in fiscal year 2011.
        A study in the Journal of Clinical Oncology projects that the
    number of new cancer cases diagnosed each year will jump 45 percent in
    the next 20 years. In multiple myeloma an even greater increase (57
    percent) is projected, and we are already seeing increasing diagnoses
    in patients under age 65 including patients in their 30s, in what was
    once a rare disease of the elderly.
        While a number of cancers have achieved 5-year survival rates of
    over 80 percent since passage of the National Cancer Act of 1971,
    significant challenges still remain for other cancers. In fact, more
    than half of the 562,340 cancer deaths in 2009 were caused by just
    eight forms of cancer with 5-year survival rates of 45 percent or
    less--of which myeloma is one. Yet, myeloma and these other cancers
    have historically also received the least amount of Federal funding. As
    we have seen mortality rates of diseases such as breast cancer,
    prostate cancer, AIDS, and childhood leukemia greatly reduced through
    targeted, comprehensive, and well-funded programs that have led to
    earlier detection and superior forms of treatment, so too must we shine
    a brighter light on myeloma and the other seven deadly cancers to
    achieve this same goal for them. The IMF urges Congress to allocate
    $5.957 billion to the National Cancer Institute (NCI) in fiscal year
    2011 to continue our battle against myeloma.
    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 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 2011 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 2011
    funding levels necessary to ensure that our Nation continues to make
    gains in the fight against myeloma.
                                     ______

              Prepared Statement of the Jeffrey Modell Foundation

        Mr. Chairman and members of the subcommittee: Thank you for the
    opportunity to present this testimony to the subcommittee. My husband
    Fred and I created the Jeffrey Modell Foundation in 1987 in memory of
    our son, Jeffrey, who died at the age of 15 as a result of a life long
    battle against one of the estimated 160 primary immunodeficiency (PI)
    diseases.
        The Jeffrey Modell Foundation is an international organization with
    its headquarters in New York City. In the 24 years since we established
    it, the Foundation has grown into the premier advocacy and service
    organization on behalf of people afflicted with PI diseases. As a
    demonstration of the extent to which the JMF leads in the field, please
    consider the following:
      --The Foundation has created Jeffrey Modell Research and Diagnostic
            Centers at 72 academic and teaching hospitals from coast to
            coast in the United States and throughout the world. They are
            located on every continent. In addition, we are affiliated with
            more than 415 referring physicians at 171 academic medical
            centers in 59 countries and 169 cities, again located on every
            continent throughout the world.
      --The Foundation conducts a National Physician Education and Public
            Awareness Campaign, currently funded with approximately $3.1
            million appropriated by this subcommittee to the Centers for
            Disease Control and Prevention (CDC) and awarded by competitive
            contract to the Foundation. To date, the Foundation has
            leveraged the Federal money to generate in excess of $125
            million in donated media with hundreds of thousands of
            placements on television, radio, print, and other public media,
            as well as a 30-minute program produced for PBS. The Campaign
            has also included physician symposia, conducted for CME credits
            in locations throughout the country. It has also included
            mailings to physicians in a variety of specialist and primary
            care fields, including pediatrics and several pediatric
            specialties, family practice, and internal medicine, as well as
            school nurses, clinical and registered nurses and daycare
            centers.
      --In addition, the Jeffrey Modell Foundation has been the leader in
            advancing newborn screening for some of the most severe forms
            of PI. Working with the CDC, National Institutes of Health
            (NIH), UCSF and private industry, we helped fund the
            development of a newborn screening test that was pilot tested
            in Wisconsin. The results were so successful that Wisconsin and
            Massachusetts have now implemented population-based screening
            of every baby born in their States. Then, in January of this
            year, we were successful in having the Secretary's Advisory
            Committee for Children with Heritable Disorders add this test
            to the core panel of 29 newborn screening tests recommended for
            the States to utilize. It is the first test to be added since
            the core panel was created in 2005. The test is already saving
            lives and we know that as more states adopt it, many more will
            be saved.
        First and foremost, Mr. Chairman, we want to thank you and all the
    members of this subcommittee on both a personal and a professional
    level. Personal because whenever we come to Washington, whether it is
    to testify here before the subcommittee or to meet with the members of
    the subcommittee individually in their offices, every Member of
    Congress and every member of your staffs are unfailingly polite,
    courteous, interested, and caring. The warm and understanding response
    that we receive makes this a labor of love for us.
        And, professional because over the 12 years that we have been
    coming to Washington, we have been given the opportunity to build a
    partnership with the Congress, CDC, NIH, as well as with our own
    supporters in the private sector, including industry and other
    concerned donors. We believe that we have maximized the benefits for
    patients from the support that this subcommittee has afforded us. I
    would like to take a few minutes to discuss where we are, where we are
    going with your continued support, and some changes that are need in
    the President's budget request to help us help patients.
    PI Education and Awareness Program
        This subcommittee is currently providing CDC with $3.1 million for
    physician education and public awareness of immunodeficiencies for
    fiscal year 2010. This is part of an overall budget of $12.3 million
    for the Office of Public Health Genomics, which uses the remaining $9.2
    million for its operations.
        Since the Campaign's inception, it has generated more than $125
    million in donated media, including television and radio spots,
    magazine ads, billboards, airport signs, and other print media. It has
    also enabled us to generate additional funding from the private
    sector--both individuals and the pharmaceutical industry. To this
    point, every $1 of Federal funds provided by the subcommittee to this
    program has been leveraged into more than $10 for this education and
    awareness program.
        Most importantly, Mr. Chairman, I am delighted to report to you
    that the program that this subcommittee has funded is having exactly
    the impact that all of us hoped it would when it was created. Allow me
    to give you some specifics.
        Surveying the physicians at the Jeffrey Modell Centers Referral
    Network we have learned that the number of patients referred, diagnosed
    and treated has doubled every year since the program's inception. The
    negative health outcomes of undiagnosed cases--infections, hospital and
    physician visits, and similar costs--decrease an average of 70 percent
    for diagnosed patients.
        But, it is fair of this subcommittee to ask ``so what?'' What
    difference does it make to the health of these patients if they are now
    in treatment? What is the real impact in a real world sense on the
    patients that are found?
        The economic impact of PI diagnosis has been carefully assessed
    comparing the costs of treatment before diagnosis and after. In round
    numbers what we learned was that the average annual cost of healthcare
    for an undiagnosed patient is $103,000 per year. The same costs for the
    same patients in the year after diagnosis are $23,000. The gross annual
    savings to the healthcare system is $80,000 per patient.
        Mr. Chairman, this program is working and we are delighted. But
    this is where the problem comes along. The President's budget for
    fiscal year 2011 reduces funding for the Office of Public Health
    Genomics from $12.3 million to $11.7 million. Further it eliminates the
    line item created by this subcommittee to fund the education and
    awareness program. While CDC has indicated its support for continuing
    the program, the only guarantee that will happen is if you act.
        For this reason, we are asking that you take three modest steps as
    you are assembling the Chairman's mark for the bill:
      --First, restore the total line item for the Office of Public Health
            Genomics to its fiscal year 2010 level of $12,308,000.
      --Second, break that money out into two separate lines, as its now--
            $9,201,000 for the Office and $3,107,000 for PI Education and
            Awareness.
      --Third, so that there is no misunderstanding, include a paragraph of
            Committee Report language that says:

        ``The subcommittee believes that the education and awareness
    program for primary immunodeficiencies has been a model of public-
    private cooperation and therefore has restored the current structure
    for the Office of Public Health Genomics budget. The program's success
    in leveraging public money for private investment has resulted in a
    huge return on the Federal dollar, led to reduced health disparities,
    and will save lives as the program directs greater attention to newborn
    screening.''
    Newborn Screening Program
        As described above, early diagnosis is critical to the health of
    patients and to saving the healthcare system money. And, there are few
    better examples of early diagnosis than newborn screening. The JMF has
    worked long and hard to support the development of a newborn screening
    program for some of the most severe and deadly forms of PI.
        Early detection of these diseases through newborn screening is
    critical because bone marrow transplants cure more than 98 percent of
    infants who have the procedure before developing any serious
    infections. The treatment costs less than $10,000. However, if an
    infant receives a transplant after developing severe infections, the
    success rate is only between 60 and 70 percent; the costs associated
    with the treatment of these infants can be as high as $1 million during
    their lifetime.
        As described above, the Secretary's Advisory Committee on Children
    with Heritable Disorders has recommended to the Secretary that this
    test be added to the core panel that forms the basis of newborn
    screening in States throughout the Nation. It is the first time the
    list has ever been amended since it was created 5 years ago. The
    Jeffrey Modell Foundation is proud to have played a role in this
    advancement for babies and we are urging the Secretary to accept the
    recommendation promptly.
        Once she has done so, newborn screening officials in numerous
    States have advised us that they will move forward with including this
    test in their States. At that time, the Foundation is committed to
    moving forward with the production of educational materials for State
    labs and families that will provide the information they need to
    consider the results of the test their baby is having. The funds for
    the education and awareness program are critical for making the most of
    this important improvement in public health.
    Conclusion
        With the support the Jeffrey Modell Foundation has received from
    this subcommittee over the years, we have been able to increase the
    public's awareness of PI and most importantly improve and save lives.
    We are grateful for your past and continued support. While we
    understand that the subcommittee must make difficult decisions in this
    fiscal environment, please remember that the Foundation has
    successfully leveraged Federal dollars to expand the reach of all of
    our activities. Frankly, the collaboration between the Federal
    government and the Jeffrey Modell Foundation has been a model for
    successful public-private collaborations. The impact of every Federal
    dollar spent on the education and awareness campaign and on newborn
    screening has been exponentially increased by our commitment to bring
    the Foundation's resources to bear.
        We ask again that you restore the funding to fiscal year 2010
    levels; break out PI Education and Awareness into a separate line item;
    and include the report language provided to assure that this program
    maximizes its impact.
        Mr. Chairman, again, we are delighted to have the opportunity to
    present to the subcommittee and stand ready to work with you.
                                     ______

                    Prepared Statement of Knowledge Alliance

        On behalf of Knowledge Alliance, we are pleased to submit this
    testimony to the subcommittee regarding our recommendations for the
    fiscal year 2011 Labor, Health and Human Services, and Education, and
    Related Agencies appropriations bill as they relate to the U.S.
    Department of Education.
        Knowledge Alliance is a nonprofit, nonpartisan trade association
    dedicated to expanding the use of research-based knowledge in policy
    and practice in K-12 education. We are a strong and dynamic community
    of highly successful education organizations and agencies, all of which
    are constantly looking for new and better ways to support high-quality
    education research, development, dissemination, technical assistance,
    and evaluation at the Federal, regional, State, tribal, and local
    levels.
        Much of our collective work is focused on advancing the effective
    use of research-based knowledge as catalyst for innovation and
    transformation in K-12 education and as a central organizing concept
    for education reform moving forward. We firmly believe that the
    effective creation, translation, and application of research-based
    knowledge can significantly accelerate and bring to scale nationwide
    efforts to improve academic performance and close achievement gaps for
    all students. Effective knowledge use also helps advance the national
    initiatives to transform education into an evidence-based field and
    enhance the implementation of the American Recovery and Reinvestment
    Act (ARRA), the Elementary and Secondary Education Act (ESEA) and the
    Education Sciences Reform Act.

                              CRITICAL CHALLENGES

        We believe that now is the time to intensify the focus on creating,
    translating, and applying research-based knowledge into useful tools
    that will improve classroom policies and practices in all schools for
    the following critical reasons:
        Seriously Deficient Investments in Education R&D.--ESEA requires
    educators to use instructional practices and innovations supported by
    research, but the Department of Education spends less than 1 percent of
    its budget on research, development and statistics, the smallest of any
    Cabinet-level agency.

                            [in billions of dollars]
    ------------------------------------------------------------------------
                                                                Fiscal year
                                                               2009 research
                    Federal department/agency                       and
                                                                development
                                                                  request
    ------------------------------------------------------------------------
    Defense.................................................           $80.7
    Health and Human Services...............................            29.9
    NASA....................................................            10.7
    Energy..................................................            10.6
    National Science Foundation.............................             5.2
    Agriculture.............................................               2
    Commerce................................................             1.2
    Homeland Security.......................................             1.1
    Transportation..........................................             901
    Veterans Affairs........................................             884
    Interior................................................             617
    Environmental Protection Agency.........................             550
    Education...............................................            324
    ------------------------------------------------------------------------
    Source: American Association for the Advancement of Science.

        This low level of investment means that education is ill equipped
    to rapidly develop, deliver, and scale innovations as is done in other
    sectors through R&D. The bottom line is that schools and students will
    suffer without an increased investment in developing and testing
    research-based practices.
        Rapidly Expanding Capacity Crisis.--According to a recent Center on
    Education Policy report, about one-third of U.S. public schools did not
    make AYP in school year 2008-2009. In nine States and the District of
    Columbia, at least half the public schools did not make AYP in 2008-
    2009. In a majority of the States (35 including D.C.), at least one-
    fourth of the schools did not make AYP. States and districts currently
    lack the sufficient funds, staff, and expertise to address the growing
    demand to support low-performing schools. This capacity crisis only
    exacerbates the complex challenges of transforming low-performing
    schools and preparing all schools for the next generation of learning.
        Urgent Need for Solutions.--Federal education policy has evolved in
    phases over the past 15 years. The focus on standards and assessments
    in the late 1980s and early 1990s spawned major attention on the
    alignment of standards, curriculum, and assessments in the 1990s, which
    played a role in the current emphasis on accountability. The next
    logical step in this standards-based continuum is a more comprehensive
    and vigorous focus on solutions to bring about real school improvement
    by providing significant new resources and expertise targeted to
    turning around low-performing schools and to building a knowledge-based
    capacity and infrastructure for sustained improvement.

                                RECOMMENDATIONS

        Our appropriations proposal for fiscal year 2011 calls for greater
    Federal investments in research-based programs to help States and
    districts respond to the rapidly increasing needs We urge a stronger
    and more comprehensive Federal effort to respond both to the greater
    demand for knowledge-based solutions and to the underfunded supply of
    well-tested practices and programs. Specifically, we propose the
    following:

         TOP PRIORITY: A KNOWLEDGE, INNOVATION, AND IMPROVEMENT PACKAGE

        We urge you to consider six essential and interrelated programs as
    a knowledge-innovation-improvement package:
    Comprehensive Centers
        Recommendation: $67.3 million ($10 million increase more than
    President's request for fiscal year 2011).
        Our proposed recommendation includes an increase of $500,000, or 20
    percent, of additional funding for each Comprehensive Center which
    would enable the 16 regional centers to expand their capacity building
    work with SEAs in such areas as resource allocation, data use, teacher
    effectiveness and school improvement. In addition, the proposed
    increase would support the five content centers school improvement
    efforts in providing in-depth, specialized support in five key areas
    focusing on assessment and accountability, instruction, teacher
    quality, innovation and improvement and high schools. The increase
    would also enable the Centers to help States sustain their one-time
    ARRA school improvement efforts.
    Regional Educational Laboratories
        Recommendation: $80.6 million ($10 million increase more than
    President's request for fiscal year 2011).
        The Regional Educational Laboratory Program is composed of a
    network of 10 laboratories that serve the education reform and school
    improvement needs of designated regions through rigorous research
    studies and rapid response reports. Our proposed increase would expand
    a special triage ``urgent response'' system to address the most
    pressing, immediate educational reform issues in each region. This
    request, if fulfilled, would enable the labs to further support the
    crucial initiatives that are being implemented via the ARRA.
    Research, Development, and Dissemination
        Recommendation: $261 million (same as the President's request for
    fiscal year 2011).
        Our recommendation would allow IES to continue to fund more high-
    quality applications under existing programs of research, development,
    and dissemination in areas where the knowledge of learning and
    instruction is inadequate. This recommendation would also enable IES to
    invest in new grants to support evaluations at the State and district
    level to evaluate whether reforms undertaken with funds awarded under
    ARRA are producing the desired improvements on student achievement and
    other critical outcomes. Finally, the recommended boost of $175 million
    would create a sustainable venture fund for investing in what works in
    education reform, as conceived in ARRA.
    School Turnaround Grants
        Recommendation: $900 million (same as the President's request for
    fiscal year 2011).
        The $354.4 million increase requested for the School Turnaround
    Grants (currently School Improvement Grants) program would help build
    State and local capacity to identify and implement effective
    interventions to turn around their lowest-performing schools. The
    proposed increase would create a sustainable base for long-term school
    improvement efforts.
    Investing in Innovation Fund
        Recommendation: $500 million (same as the President's request for
    fiscal year 2011).
        The request would support a newly authorized ESEA program, modeled
    after the i3 program authorized by the ARRA. The proposed request would
    also provide a substantial Federal investment for scaling and
    sustaining evidence based innovations. The request is a bold step in
    the right direction in building from and on a knowledge base for
    reform.
    Race to the Top
        Recommendation: $1.35 billion (same as the President's request for
    fiscal year 2011).
        The request would support a newly authorized ESEA program, modeled
    after the Race to the Top program authorized by the ARRA. The program
    would create incentives for State and local reforms and innovations
    designed to support comprehensive reforms that lead to significant
    improvements in student achievement and close the achievement gaps. The
    program would also encourage the broad identification, dissemination,
    adoption, and the use of effective policies and practices.
     important support: programs contributing to innovation and improvement
        We recommend continued support for the following programs which
    will play an increasingly significant role in State and local efforts
    to respond to the escalating demand for school improvement and
    solutions.
      --21st Century Community Learning Centers Recommendation: $1.16
            billion (same as the President's request)
      --Education for Homeless Children and Youth Recommendation: $65.4
            million (same as the President's request)
      --English Language Acquisition Recommendation: $800 million (same as
            the President's request)
      --Even Start Recommendation: $66.4 million (same as fiscal year 2010)
      --High School Graduation Initiative Recommendation: $100 million ($50
            million increase more than fiscal year 2010)
      --Improving Teacher Quality State Grants Recommendation: $2.94
            billion (same as fiscal year 2010)
      --Math Science Partnerships (ED) Recommendation: $180.5 million ($1.5
            million increase more than fiscal year 2010)
      --National Center for Education Statistics Recommendation: $117
            million (same as the President's request)
      --Parental Information and Resource Centers Recommendation: $39.4
            million (same as fiscal year 2010)
      --Smaller Learning Communities Recommendation: $88 million (same as
            fiscal year 2010)
      --Special Education Research and Evaluation programs Recommendation:
            $82 million (same as the President's request)
      --Statewide Data Systems Recommendation: $100 million (same as the
            President's request)
      --Striving Readers Recommendation: $370 million ($120 million
            increase more than fiscal year 2010)
      --Technology State Grants Recommendation: $100 million (same as
            fiscal year 2010)
        In total, we believe it has never been more important to expand the
    Federal supported knowledge-innovation-improvement infrastructure and
    to deliver research-based solutions to schools with the greatest needs
    to improve. Congress is uniquely positioned to turn the page on past
    efforts and to lead us into a new era of innovation and transformation
    of our public school system.
        Indeed now is the time to unleash America's ingenuity to solve our
    most pressing education problems, deliver break-the-mold solutions to
    our schools, and guide a new knowledge and innovation revolution in
    teaching and learning.
        Thank you for your consideration.
                                     ______

         Prepared Statement of the Lions Clubs International Foundation

        I would like to begin by thanking Chairman Tom Harkin, Ranking
    Member Thad Cochran and members for the opportunity to provide this
    testimony on spending priorities before the Labor, Health and Human
    Services, and Education, and Related Agencies Subcommittee. I would
    also like to congratulate you, Mr. Chairman, and your colleagues, for
    examining the way service organizations can collaborate with the
    Federal Government in meeting pressing community needs for improved
    health and education services.
        Lions Clubs International represents the largest and most effective
    NGO service organization presence in the world. Awarded and recognized
    as the #1 NGO organization for partnership globally by The Financial
    Times 2007, Lions Clubs International also holds the highest four star
    (highest) rating from the CharityNavigator.com (an independent review
    organization). Lions and its official charity arm, Lions Clubs
    International Foundation (LCIF), have been world leaders in serving the
    vision, hearing, youth development, and disability needs of millions of
    people in America and around the world, and we work closely with other
    NGOs such as Special Olympics International to accomplish our common
    service goals. Since LCIF was founded in 1968, it has awarded more than
    9,000 grants, totaling more than $640 million for service projects
    ranging from affordable hearing aids to diabetes-prevention.
        Our current 1.3 million-member global membership, representing over
    200 countries, serves communities through the following ways: protect
    and preserve sight; provide disaster relief; combat disability; promote
    health; and serve youth. The 14,000 individual Lions Clubs representing
    400,000 individual citizens in North America are constantly expanding
    to add new programs its volunteers are working to bring health services
    to as many communities as possible.
        Some of our major collaborative partners include: Habitat for
    Humanity, Special Olympics, the U.S. National Eye Institute, CADCA
    (Community Anti-Drug Coalition of America), Service Nation and many
    others.
        Today, we face many complex challenges in the health and education
    sector, from preventable diseases that cause blindness in children to
    bullying, violence, and drug use among school-aged children. I will
    offer a brief summary of my remarks through an overview of where Lions
    Clubs International is involved in programs under the general
    jurisdiction of the Labor, Health and Human Services, and Education,
    and Related Agencies Subcommittee, and where we recommend areas where
    Federal partnerships should be maintained and strengthened.

                           HEALTH AND HUMAN SERVICES

        Domestic Sight Services.--Through our network of foundations and
    programs across America, Lions remains the single largest provider of
    charitable vision care, eyeglasses and hearing care services to needy
    and indigent people. Some of our major sight initiatives include:
      --The Sight for Kids Program in collaboration with Johnson and
            Johnson. The program has provided 6 million vision screenings
            and eye-health education programs for children.
      --Core 4 Preschool Vision Screening program enables Lions to conduct
            screenings for children in preschools. The program strives to
            deliver early detection and treatment for the most common
            vision disorders that can lead to amblyopia or ``lazy eye.''
            LCIF has also provided grants and services to those affected by
            eye conditions that cannot be improved medically.
      --Last August Lions Clubs sponsored ``United We Serve Health Week''
            Signature Events around the country. These Health Week efforts,
            in conjunction with the White House, were effective in bringing
            awareness to vision health issues.
    Vision Health Recommendations
        Last year, the U.S. House overwhelmingly passed H.R. 577, the
    Vision Care for Kids Act, a bill that provides for comprehensive eye
    examinations to eligible children who have been screened, and to
    provide treatment or services to these children. We strongly support
    efforts to pass the Senate companion bill, Senator Kit Bond's S. 259.
        Our network of clubs, foundations and institutions continue to
    supplement public health efforts in this area through free vision
    screenings, fittings for eyeglasses, free prescription eyeglasses, and
    health education programs. The Lions eye-screening program for our
    youngest and most vulnerable citizens has potential to expand output
    with the securing of significant support from policymakers in States
    and districts with strong Lions Club participation. This is
    particularly relevant in providing mobile eye screening programs for
    glaucoma and amblyopia treatment and follow up services in areas that
    are economically disadvantaged and include high-risk urban and rural
    populations.
        There is recent congressional support for the continuation and
    expansion of collaborative efforts between the Office of Head Start and
    stakeholders to ensure that all Head Start enrollees receive vision
    screening services and other resources available to them in their
    community. This is an effective means of ensuring that congressionally
    directed funding serve the communities where mobile screening units and
    preschool testing is most needed in a cost-effective manner. Again, for
    many localities in need of screening services, there is ample
    opportunity to expand comprehensive vision screening services so that
    no children are ``left to fall through the cracks.''
    Special Olympics ``Healthy Athletes'' Program
        Lions Clubs International is a central part of a global team of
    healthcare volunteers who participate in the Special Olympics Healthy
    Athletes program. The Opening Eyes program is a vision and eye health
    screening program that has provided some 100,000 visions screenings for
    Special Olympic Athletes. More than 40,000 Special Olympic athletes
    have received free prescription eyeglasses to date.
        Lions supports further congressional funding for ``Healthy
    Athletes'' and its crucial mission to: improve access and healthcare
    for Special Olympics athletes; make referrals to local health
    practitioners when appropriate; train healthcare professionals and
    students about the needs and care of people with intellectual
    disabilities; collect, analyze and disseminate data on the health
    status and needs of people with intellectual disabilities; and advocate
    for improved health policies and programs for people with intellectual
    disabilities.
    Lions Affordable Hearing Aid Project (AHAP)
        Lions Clubs International is committed to fighting hearing loss as
    well as blindness. By listening to community health organizations
    across the country, Lions Clubs International and their volunteer
    members became aware of the lack of quality and affordable hearing
    care, especially for people with incomes below or at 200 percent of the
    poverty level. Many people have been unable to access other personal
    and family resources to purchase hearing aids, and have been denied
    State and Federal assistance. Lions Clubs 14 centers have been working
    to expand output in this area as demand continues to rise with a
    network of mobile health units and community based programs that screen
    more than 2 million people each year and provide hearing aids to 14,000
    low income patients.
        The statistics are unacceptable: 31 million persons in the United
    States experience some form of hearing loss, yet only 7.3 million opt
    to use hearing aids. According to audiology researchers, the market
    penetration for hearing aids is about 23.6 percent. For every four
    patients that enter a practice needing hearing aids, only one will
    purchase them. The median price tag is $1,900 (2005) for a digital
    hearing aid and prices go as high as $4,000. State Foundations, public
    health departments, and aging departments are in need of assistance in
    this area.
        With the recent 25-30 percent increase in people seeking assistance
    for hearing aids, there is an immediate public imperative to address
    the problem. Federal dollars are stretched, but Federal support in this
    area would have significant public health dividends in difficult
    economic times.

                       ``LIONS QUEST''/EDUCATION PROGRAMS

        Lions Clubs International's youth development initiatives, known
    collectively as ``Lions Quest,'' have been a prominent part of school-
    based K-12 programs since 1984. Fulfilling its mission to teach
    responsible decisionmaking, effective communications and drug
    prevention, Lions Quest has been involved in training more than 350,000
    educators and other adults to provide services for more than 11 million
    youth in programs covering 43 States. LCIF currently invests more than
    $2 million annually in supporting life skills training and service
    learning, and that funding is matched by local Lions, schools, and
    other partners.
        Lions Quest curricula incorporate parent and community involvement
    in the development of health and responsible young people in the areas
    of: life skills development (social and emotional learning), character
    education, drug prevention, service learning, and bullying prevention.
    There is even a physical fitness component to this program that can
    assist Federal goals of reducing obesity in school-aged children.
        These Lions Quest programs provide strong evidence of decreased
    drug use, improved responsibility for students own behavior, as well as
    stronger decisionmaking skills and test scores in math and reading. In
    August 2002, Lions Quest received the highest ``Select'' ranking from
    the University of Illinois at Chicago-based Collaborative for Academic,
    Social and Emotional Learning (CASEL) for meeting standards in life
    skills education, evidence of effectiveness and exemplary professional
    development.
        Lions Quest has extensive experience with Federal programs. Lions
    Quest Skills for Adolescence received a ``Promising Program'' rating
    from the U.S. Department of Education Safe and Drug Free Schools and a
    ``Model'' rating from the U.S. Department of Health and Human Services
    Substance Abuse and Mental Health Services Administration (SAMHSA).
        Lions Quest also has extensive experience of partnering with State
    service commissions to reach more schools and engage more young people
    in service learning. Successful partnerships have been active in
    Michigan, New York, Oklahoma, Tennessee, and West Virginia with
    progress being made in Texas and Ohio.
    Service Learning Initiatives
        Lions Quest has also pursued Learn and Serve Grant funding to
    support implementation of Lions Quest programming in several States. We
    strongly support Congressional efforts to fund the Edward M. Kennedy
    Serve America Act that was signed into law 1 year ago. The Serve
    America Act authorizes the Corporation for National and Community
    Service to expand existing programs and add several new programs and
    initiatives to provide service learning school-based programs for
    students as well as Innovative and Community-Based Service-Learning
    Programs and Research. Another program of value that was authorized by
    the Edward M. Kennedy Act is the Social Innovation Fund that provides
    growth capital and other support so that the most effective programs
    can be identified.
    Social and Emotional Learning (SEL) Programs
        In addition, Lions Clubs recommends Congressional support for
    social and emotional learning (SEL) programs that stimulate growth
    among schools nationwide through distribution of materials and teacher
    training, and to create opportunities for youth to participate in
    activities that increase their social and emotional skills. Not only do
    SEL curricula contribute to the social and emotional development of
    youth, but they also provide invaluable support to students' school
    success, health, well-being, peer and family relationships, and
    citizenship. While still conducting scientific research and reviewing
    the best available science evidence, over time Lions Clubs and its SEL
    partners have increasingly worked to provide SEL practitioners,
    trainers and school administrators with the guidelines, tools,
    informational resources, policies, training, and support they need to
    improve and expand SEL programming.
        Overall, SEL training programs and curricula have outstanding
    benefits for school-aged children:
      --SEL prevents a variety of problems such as alcohol and drug use,
            violence, truancy, and bullying. SEL programs for urban youth
            emphasize the importance of cooperation and teamwork.
      --Positive outcomes increase in students who are involved in social
            and emotional learning programming by an average of 11
            percentile points over other students.
      --With greater social and emotional desire to learn and commit to
            schoolwork, participants benefit from improved attendance,
            graduation rates, grades, and test scores. Students become
            caring, concerned members of their communities.

                                   CONCLUSION

        Lions Clubs remains committed to domestic activities such as major
    sight initiatives and positive youth development and youth service
    programs. Today we face great health and educational challenges, and
    Lions Clubs International understands the importance not only of
    community service but of instilling those values among members of our
    next generation. The success of nonprofit entities such as Lions Clubs
    show what the service sector can do for economic and social development
    of communities that are especially hard hit by the recession, and we
    are committed to forming more effective alliances and partnerships to
    increase our domestic impact. We look forward to working with you and
    your colleagues on taking up these important challenges.
                                     ______

         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. It was a shock to me and my family, friends, and clients.
        One morning 4 years ago, when doing a load of laundry, I had no
    idea how to set the dials, despite the fact that I had used these dials
    weekly for the last 10 years. I stood there for what seemed an eternity
    before I figured out how to set them.
        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 ER, 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 post-stroke
    depression was harder than the recovery of my arms and legs and even
    speech.
        Being a psycho-therapist, 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 4 years post-stroke, I am back to full-time
    practice. I lead support groups for stroke survivors and caregivers
    through the Montgomery County Stroke Association and serve on its
    Board. I also lecture on stroke, stroke prevention, and stroke
    recovery. I founded ``Hope after Stroke''--individual and family
    counseling for stroke survivors and caregivers. In addition, I have
    participated in NIH studies about stroke recovery.
        Once again, I am in excellent health and have resumed my active
    life style. 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/National Mentoring Partnership

        Chairman Harkin and Ranking Member Cochran, I thank you for the
    opportunity on behalf of MENTOR/National Mentoring Partnership to
    submit written testimony in support of resources for youth being
    mentored or in need of a caring, screened, and trained mentor.
    Specifically, we ask your continued support for the:
      --Mentoring Children of Prisoners program, and
      --Serve America Act programs that support youth mentoring.
        First, we thank you for previous support of the U.S. Department of
    Health and Human Services' (HHS) Mentoring Children of Prisoners
    program and request that you include level funding for the program in
    fiscal year 2011. MENTOR has appreciated the support of the
    subcommittee in previous years, in funding this competitive grant
    program at roughly $50 million since fiscal year 2004. We applaud
    President Obama for including level funding in his fiscal year 2011
    budget for this program at $49.3 million.
        This authorized program provides competitive grants to local
    mentoring organizations to help them match children of incarcerated
    parents with caring adult mentors. As noted by the Administration for
    Children and Families, Faith-Based and Community Initiative,\1\ more
    than 2 million children and youth in the United States have at least
    one parent in a Federal or State correctional facility. Furthermore,
    the Initiative writes:
    ---------------------------------------------------------------------------
        \1\ http://www.acf.hhs.gov/programs/fbci/progs/fbci_mcp.html

        ``In addition to experiencing disruption in the relationship with
    their parent, these young people often struggle with the economic,
    social, and emotional burdens of the incarceration. Data indicate that
    mentoring programs can help young people, including those with
    incarcerated parents, by reducing their first-time drug and alcohol
    use, improving their relationships and academic performance, and
    reducing the likelihood that they will initiate violence. In addition,
    mentoring programs can provide these children with opportunities to
    develop a trusting relationship with a supportive adult and a stable
    ---------------------------------------------------------------------------
    environment that can promote healthy values and strong families.''

        In addition, since 2007, MENTOR/National Mentoring Partnership has
    served as the administrator of the Mentoring Children of Prisoners:
    Caregiver's Choice voucher demonstration project (Federal Grant
    #90CV0457). Caregiver's Choice allows caregivers and parents the
    opportunity to directly connect their children with quality mentoring
    programs. Programs that meet quality standards created by experts--in
    mentoring and working with families of the incarcerated--have been
    selected to take part. This 3-year demonstration project has
    consistently met its goals.
        We ask for your continued support to ensure that HHS honors all
    mentoring relationships established between eligible children and
    enrolled programs under the Mentoring Children of Prisoners program.
        Second, the mentoring field as a stream of service was provided a
    boost through the passage and enactment of the Edward M. Kennedy Serve
    America Act. We support President Obama's fiscal year 2011 budget
    request for Serve America Act Programs under the Corporation for
    National and Community Service. This includes $914.3 million for
    AmeriCorps, $60 million for the Social Innovation Fund, $10 million for
    the Volunteer Generation Fund, $40.2 million for Learn and Serve
    America, and $221 million for Senior Corps.
        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 (RSVP), 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 2011 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. Indeed, in its fiscal year 2011 budget justification,\2\
    the Corporation notes mentoring several times in its fiscal year 2009
    performance outcomes, such as in an increase to 65,696 children of
    prisoners mentored through VISTA--well above its target of 50,000 for
    fiscal year 2009. 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.
    ---------------------------------------------------------------------------
        \2\ http://www.nationalservice.gov/pdf/
    2011_budget_justification.pdf
    ---------------------------------------------------------------------------
        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 4,700 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 4,700 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 (DuBois et al., 2002)
    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, Eby, Allen, Evans, Ng
    and DuBois (2008) 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 BBBSA's newer, school-based mentoring
    (Herrera, Grossman, Kauh, Feldman, and McMaken, 2007) 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.
        Mentoring's Impact on the Drop Out Rate.--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.\3\ \4\
    ---------------------------------------------------------------------------
        \3\ Bridgeland, John M. et al. (2006). The Silent Epidemic:
    Perspectives of High School Dropouts. Civic Enterprises in Association
    with Peter D. Hart Research Associates for the Bill & Melinda Gates
    Foundation.
        \4\ Harmacek, Marilyn, ed. (2002). Youth Out of School: Linking
    Absences to Delinquency. 2nd Edition. Colorado: The Colorado Foundation
    for Families and Children.
    ---------------------------------------------------------------------------
        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,\5\ which is linked to higher levels of classroom
            engagement and higher grades.\6\
    ---------------------------------------------------------------------------
        \5\ Linnehan, F. (2005) ``The relation of a work-based mentoring
    program to the academic performance and behavior of African American
    students,'' Journal of Vocational Behavior, 59(3).
        \6\ Utman, C. H. (1997). Performance effects of motivational state:
    A meta-analysis. Personality and Social Psychology Review, 1, 170-182.
    ---------------------------------------------------------------------------
      --School-based mentoring enhances connectedness to schools, peers and
            society,\7\ and mentored youth have more positive attitudes
            toward school and teachers.\8\
    ---------------------------------------------------------------------------
        \7\ Karcher, M.J. (2005). ``The effects of school-based mentoring
    and high school mentors' attendance on their younger mentees' self-
    esteem, social skills and connectedness.'' Psychology in the Schools.
        \8\ Jekielek, Susan M. et al. (2002). Mentoring: A Promising
    Strategy for Youth Development. ChildTrends Research Brief, Washington,
    DC.
    ---------------------------------------------------------------------------
      --Evaluations of mentoring programs indicated that both one-to-one
            mentoring and group mentoring result in better school
            attendance for mentored youth.\9\
    ---------------------------------------------------------------------------
        \9\ Sipe, Cynthia L. (1999). Mentoring Adolescents: What have we
    learned? Contemporary Issues in Mentoring, Grossman, Jean Baldwin (ed),
    Public/Private Ventures.
    ---------------------------------------------------------------------------
      --Mentored youth experience improvements in parental relationships
            and their own sense of self-worth.\10\
    ---------------------------------------------------------------------------
        \10\ Jekielek, Susan M., et al. (2002). Mentoring Programs and
    Youth Development: A Synthesis. ChildTrends, Washington, DC.
    ---------------------------------------------------------------------------
      --Mentored youth are significantly less likely to participate in
            high-risk behaviors, including substance abuse, carrying a
            weapon, unsafe sex, and violent behaviors.\11\
    ---------------------------------------------------------------------------
        \11\ Beier, Rosenfeld, Spitalny, Zansky, and Bontemmpo. (2000).
    ``The potential role of an adult mentor in influencing high-risk
    behaviors in adolescents.'' Archives of Pediatric Medicine 15.
    ---------------------------------------------------------------------------
        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.
        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.\12\ 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.
    ---------------------------------------------------------------------------
        \12\ Dubois, D.L. (2000) ``Effectiveness of Mentoring Programs for
    Youth: A Meta-analytic Review,'' American Journal of Community
    Psychology, 30(2). and Public/Private Ventures (2000). Mentoring
    School-Age Children: Relationship Development in Community-Based and
    School-Based Programs.
    ---------------------------------------------------------------------------
        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.
        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.
                                     ______

               Prepared Statement of Mended Hearts, Incorporated

        I am Robert A. Scott, National Advocacy Chairman for Mended Hearts,
    Inc., a national heart disease support group with more than 275
    chapters across the United States and Canada. In 2009, accredited
    Mended Hearts volunteers visited 187,183 patients and families and are
    serving 430 hospitals throughout the United States.
        As I am a walking testimony of the benefits of National Institutes
    of Health (NIH) supported heart research, I would like to share my
    story with you. 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 may
    experience this type of episode--a heart attack with no warning just
    like I had.
        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 in Providence, Rhode Island 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 make
    it. 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 I received an implantable
    defibrillator to control the problem in 2002. However, this device had
    to replaced in Rhode Island 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. 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. My doctor explained that it could open up the original
    blockage from my silent heart attack. He added that if these state-of-
    the art stents had been available in 1998, I would not have had to have
    the heart bypass surgery.
        Despite previous treatments, I once again was faced with
    cardiovascular disease in February 2009. This time it was a stroke
    warning sign. While driving, I suddenly felt dizzy, so pulled my car
    over to stop. The next thing I knew, I had passed out for a very short
    time and felt numb on the right side of my face. This scared me enough
    that I drove myself to the hospital which just happened to be on the
    same street where I stopped my car. Upon arrival, I was a little
    confused and was later admitted into the hospital. The next day, my
    cardiologist told me I had a transient ischemic attack (TIA). My doctor
    said there was no need for a stress test and because of my heart
    condition I should have another cardiac catheterization. The
    catheterization showed that one of my arteries had minor blockage, so
    the doctor placed another stent in my artery. To date, I have not
    experienced another TIA.
        Today, heart attack, stroke, and other cardiovascular disease
    remain our Nation's most costly and number 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 me. 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 Medical Library Association

                SUMMARY OF RECOMMENDATIONS FOR FISCAL YEAR 2011

        Continue the commitment to the National Institutes of Health (NIH)
    and the National Library of Medicine (NLM) by increasing funding levels
    12 percent to $35 billion for NIH and $402 million for NLM.
        Continue to support the NIH 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 and
    support the establishment of similar policies in other Federal
    agencies.
        Continue to support the medical library community's important role
    in NLM's outreach, telemedicine, disaster preparedness, and health
    information technology (health IT) initiatives and the implementation
    of healthcare reform.
        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 (AAMC). 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 FUNDING INCREASES FOR NLM

        We are pleased that the fiscal year 2010 appropriations package
    contained funding increases for NIH and NLM and bolstered their
    baseline budgets. We encourage the subcommittee to continue to provide
    meaningful annual increases for NIH and NLM in the coming years, and
    recommend a 12 percent increase for fiscal year 2011.
        Recovery funding and the fiscal year 2010 budget increases
    stimulated the economy and biomedical research. In the case of NLM,
    Recovery Act funding allowed timely and much-needed increases in
    support for leading edge research and training in biomedical
    informatics--the kinds of programs that will influence future
    developments in health information technology. In fiscal year 2011 and
    beyond, it will be critical to augment NLM's baseline budget to
    accommodate expansion of its information resources, services, and
    programs, which must collect, organize, and make accessible rapidly
    expanding volumes of biomedical knowledge, including the influx of data
    from high-throughput genome sequencing systems and genome-wide
    association studies. Increased funding will also position NLM to
    strengthen its contributions to successful implementation of recent
    congressional priorities related to healthcare reform, health
    information technology, drug safety through its efforts to: enhance
    access to the results of comparative effectiveness research, maintain
    and disseminate health information technology standards, and to expand
    its clinical trial registry and results database in response to
    legislative requirements.

                    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 online integrated services, such as
    GenBank and PubMed that are helping to revolutionize medicine and
    advance science to the next important era which includes individualized
    medicine based on an individual's unique genetic differences. PubMed,
    with more than 20 million citations to the biomedical literature, is
    the world's most heavily used source of information about published
    results of biomedical research, and GenBank, with its international
    partners, has become the definitive source of gene sequence
    information.
        These collections stand at more than 11.4 million items--books,
    journals, technical reports, manuscripts, microfilms, photographs, and
    images. 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 come to
    expect.

                        SUPPORT AND EXTEND PUBLIC ACCESS

        The Appropriations Committee has shown unprecedented foresight and
    leadership by using the annual spending bills as the vehicle to
    establish a mandatory public access policy at the NIH. This highly
    beneficial policy, which requires all NIH-funded researchers to deposit
    their final, peer-reviewed manuscripts in NLM's PubMed Central database
    within 12 months of publication, is improving access to timely and
    relevant scientific information, stimulating discovery, informing
    clinical care, and improving public health literacy. We ask the
    Committee to remain a strong voice in support of the NIH policy, and to
    support the extension of public access policies to other Federal
    science and education agencies. MLA and AAHSL strongly support the
    expansion of public access policies to other agencies, because it would
    bring the benefits of public access to other fields of research and
    because research in other fields is increasingly relevant to
    biomedicine.

        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 and to
    train them in the most effective use of these services. 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.
        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 2011.

                      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. Presently,
    libraries are a significant, but underutilized resource for community
    disaster planning and management efforts, which NLM can help to deploy.
        NLM has the ability to work 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 NLM.

                          HEALTH IT AND BIOINFORMATICS

        NLM has played a pivotal role in creating and nurturing the field
    of medical informatics, which is the intersection of information
    science, computer science, and healthcare. Health informatics tools
    include computers, clinical guidelines, formal medical terminologies,
    and information and communication systems. For nearly 35 years, NLM has
    supported informatics research. The importance of NLM's work in health
    IT continues to grow as the Nation moves toward more interoperable
    health IT systems. 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 their 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 supporting health information technology
    initiatives in ONCHIT and the Agency for Healthcare Research and
    Quality that build upon initiatives housed at NLM.

                          BUILDING AND FACILITY NEEDS

        The tremendous growth in NLM's basic functions related to the
    acquisition, organization and preservation of an ever-expanding
    collection of biomedical literature, combined with its growing
    contributions to healthcare reform, health information technology, drug
    safety, and exploitation of genomic information is straining the
    Library's physical resources. NLM now houses 1,100 staff in a facility
    built to accommodate only 650. This increase in the volume of
    biomedical information and in the number of personnel has led to a
    serious space shortage. 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.
        MLA and AAHSL encourage the subcommittee to continue its strong
    support of NLM's goals in order to strengthen the Library's ability to
    provide support for implementation of healthcare reform. At a time when
    medical and health science libraries across the nation face growing
    financial and space constraints, ensuring that NLM continues to serve
    as the archive of last resort for biomedical collections is critical to
    the medical library community and the public we serve.
        Thank you for the opportunity to present the views of the medical
    library community.
                                     ______

                 Prepared Statement of Meharry Medical College

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Wayne J.
    Riley, President and CEO of Meharry Medical College in Nashville,
    Tennessee. I have previously served as vice-president and vice dean for
    health affairs and governmental relations and associate professor of
    medicine at Baylor College of Medicine in Houston, Texas and as
    assistant chief of medicine and a practicing general internist at
    Houston's Ben Taub General Hospital. In all of these roles, I have seen
    firsthand the importance of minority health professions institutions
    and the title VII Health Professions Training programs.
        Mr. Chairman, time and time again, you have encouraged your
    colleagues and the rest of us to take a look at our Nation and evaluate
    our needs over the next 10 years. I took you seriously and came here
    prepared to offer my best judgments. First, I want to say that it is
    clear that health disparities among various populations and across
    economic status are rampant and overwhelming. Over the next 10 years,
    we will need to be able to deliver more culturally relevant and
    culturally competent healthcare services. Bringing healthcare delivery
    up to this higher standard can serve as our Nation's own preventive
    healthcare agenda keeping us well positioned for the future.
        Minority health professional institutions and the title VII Health
    Professions Training programs address this critical national need.
    Persistent and severe staffing shortages exist in a number of the
    health professions, and chronic shortages exist for all of the health
    professions in our Nation's most medically underserved communities. Our
    Nation's health professions workforce does not accurately reflect the
    racial composition of our population. For example, African Americans
    represent approximately 15 percent of the U.S. population while only 2-
    3 percent of the Nation's healthcare workforce is African American.
        There is a well-established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than nonminority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas; (2) provide care
    for minorities; and (3) treat low-income patients.
        As you are aware, title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        Institutions that cultivate minority health professionals have been
    particularly hard-hit as a result of the cuts to the title VII Health
    Profession Training programs in fiscal year 2006 and fiscal year 2007
    Funding Resolution passed earlier this Congress. Given their historic
    mission to provide academic opportunities for minority and financially
    disadvantaged students, and healthcare to minority and financially
    disadvantaged patients, minority health professions institutions
    operate on narrow margins. The cuts to the title VII Health Professions
    Training programs amount to a loss of core funding at these
    institutions and have been financially devastating.
        Mr. Chairman, I feel like I can speak authoritatively on this issue
    because I received my medical degree from Morehouse School of Medicine,
    a historically black medical school in Atlanta. I give credit to my
    career in academia, and my being here today, to title VII Health
    Profession Training programs' Faculty Loan Repayment Program. Without
    that program, I would not be the president of my father's alma mater,
    Meharry Medical College, another historically black medical school
    dedicated to eliminating healthcare disparities through education,
    research and culturally relevant patient care.
        Minority Centers of Excellence (COE).--COEs focus on improving
    student recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions (the Medical
    and Dental Institutions at Meharry Medical College; The College of
    Pharmacy at Xavier University; and the School of Veterinary Medicine at
    Tuskegee University) to the training of minorities in the health
    professions. Congress later went on to authorize the establishment of
    ``Hispanic'', ``Native American'' and ``Other'' Historically black
    COEs. For fiscal year 2011, I recommend a funding level of $33.6
    million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and nonminority health profession institutions to support
    pipeline, preparatory, and recruiting activities that encourage
    minority and economically disadvantaged students to pursue careers in
    the health professions. Many HCOPs partner with colleges, high schools,
    and even elementary schools in order to identify and nurture promising
    students who demonstrate that they have the talent and potential to
    become a health professional. Over the last three decades, HCOPs have
    trained approximately 30,000 health professionals including 20,000
    doctors, 5,000 dentists and 3,000 public health workers. For fiscal
    year 2011, I recommend a funding level of $35.6 million for HCOPs.
        National Institutes of Health (NIH): Extramural Facilities
    Construction.--Mr. Chairman, if we are to take full advantage of the
    recent funding increases for biomedical research that Congress has
    provided to NIH over the past decade, it is critical that our Nation's
    research infrastructure remain strong. The current authorization level
    for the Extramural Facility Construction program at the National Center
    for Research Resources is $250 million. The law also includes a 25
    percent set-aside for ``Institutions of Emerging Excellence'' (many of
    which are minority institutions) for funding up to $50 million.
    Finally, the law allows the NCRR Director to waive the matching
    requirement for institutions participating in the program. We strongly
    support all of these provisions of the authorizing legislation because
    they are necessary for our minority health professions training
    schools. In fiscal year 2011, please fund this program at least at $50
    million.
        Research Centers in Minority Institutions (RCMI).--The RCMI program
    at the National Center for Research Resources has a long and
    distinguished record of helping our institutions develop the research
    infrastructure necessary to be leaders in the area of health
    disparities research. Although NIH has received unprecedented budget
    increases in recent years, funding for the RCMI program has not
    increased by the same rate. Therefore, the funding for this important
    program grow at the same rate as NIH overall in fiscal year 2011.
        Strengthening Historically Black Graduate Institutions--Department
    of Education.--The Department of Education's Strengthening Historically
    Black Graduate Institutions program (title III, part B, section 326) is
    extremely important to MMC and other minority serving health
    professions institutions. The funding from this program is used to
    enhance educational capabilities, establish and strengthen program
    development offices, initiate endowment campaigns, and support numerous
    other institutional development activities. In fiscal year 2011, an
    appropriation of $75 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        National Institute on Minority Health and Health Disparities
    (NIMHD).--NIMHD is charged with addressing the longstanding health
    status gap between minority and nonminority populations. The NIMHD
    helps health professional institutions to narrow the health status gap
    by improving research capabilities through the continued development of
    faculty, labs, and other learning resources. The NIMHD also supports
    biomedical research focused on eliminating health disparities and
    develops a comprehensive plan for research on minority health at the
    NIH. Furthermore, the NIMHD provides financial support to health
    professions institutions that have a history and mission of serving
    minority and medically underserved communities. For fiscal year 2011, I
    recommend a funding level of $500 million for the NIMHD.
        Department of Health and Human Services' Office of Minority Health
    (OMH ).--Specific programs at OMH include:
      --Assisting medically underserved communities with the greatest need
            in solving health disparities and attracting and retaining
            health professionals;
      --Assisting minority institutions in acquiring real property to
            expand their campuses and increase their capacity to train
            minorities for medical careers;
      --Supporting conferences for high school and undergraduate students
            to interest them in health careers; and
      --Supporting cooperative agreements with minority institutions for
            the purpose of strengthening their capacity to train more
            minorities in the health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities. For fiscal year 2011, I recommend a funding level
    of $75 million for the OMH.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    Meharry Medical College along with other minority health professions
    institutions and the title VII Health Professions Training programs can
    help this country to overcome health and healthcare disparities.
    Congress must be careful not to eliminate, paralyze or stifle the
    institutions and programs that have been proven to work. Meharry and
    other minority health professions schools seek to close the ever
    widening health disparity gap. If this subcommittee will give us the
    tools, we will continue to work towards the goal of eliminating that
    disparity as we have done for 1876.
        Thank you, Mr. Chairman, for this opportunity.
                                     ______

              Prepared Statement of the March of Dimes Foundation

        The 3 million volunteers and 1,400 staff members of the March of
    Dimes Foundation appreciate the opportunity to submit the Foundation's
    Federal funding recommendations for fiscal year 2011. The March of
    Dimes is a national voluntary health agency founded in 1938 by
    President Franklin D. Roosevelt to support research and services
    related to polio. Today, the Foundation works to improve the health of
    women, infants and children by preventing birth defects, premature
    birth and infant mortality through research, community services,
    education, and advocacy. The March of Dimes is a unique partnership of
    scientists, clinicians, parents, members of the business community, and
    other volunteers affiliated with 51 chapters and 213 divisions in every
    State, the District of Columbia and Puerto Rico. Additionally, in 1998,
    March of Dimes established its Global Programs to extend its mission
    overseas through partnerships with countries to deliver interventions
    directed at reducing birth defects and preterm birth. The March of
    Dimes recommends the following funding levels for programs and
    initiatives that are essential investments in the future of health of
    the Nation's children.

                                 PRETERM BIRTH

        According to a 2009 report from the National Center for Health
    Statistics (NCHS), the primary reason for the higher infant mortality
    rate in the United States compared to European nations is the greater
    percentage of preterm births--12.4 percent in the United States
    compared to 6.3 percent in Sweden. This suggests that preterm birth
    prevention is central to lowering the U.S. infant mortality rate.
    Moreover, the Institute of Medicine estimated that preterm birth cost
    the United States more than $26 billion in 2005, with costs continuing
    to climb each year.
        In June 2008, the U.S. Surgeon General sponsored a conference to
    develop a research agenda to address the costly and serious problem of
    preterm birth. More than 200 of the country's foremost researchers,
    representing a diversity of backgrounds and expertise, met for 2 days
    and created an action plan of needed steps. Within these steps, there
    are several cross-cutting themes including recommendations to enhance
    biomedical and epidemiological research and to strengthen our Nation's
    vital statistics program. The March of Dimes funding requests
    enumerated below are based on the recommendations of the Surgeon
    General's Conference.
    National Institutes of Health--Office of the Director
        The March of Dimes commends members of the Committee for supporting
    the National Children's Study (NCS) by including $193.8 million in the
    fiscal year 2010 Consolidated Appropriations Act. For fiscal year 2011,
    the Foundation supports the President's funding recommendation and
    urges the subcommittee to maintain its commitment to this vital study
    by providing $194.4 million. Currently in the pilot phase, the NCS is
    tracking the more than 150 children born to study participants. The
    data from this important effort will inform the work of scientists in
    universities and research organizations across the Nation and around
    the world, helping them identify precursors to disease and to develop
    new strategies for prevention and treatment. The first data generated
    by the NCS will provide information concerning disorders of birth and
    infancy including preterm birth and its health consequences. The
    Foundation remains committed to supporting a well-designed NCS that
    promotes research of the very highest quality.
    Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        The March of Dimes recommends a funding increase of at least 12.5
    percent for NICHD in fiscal year 2011. This increase in funding will
    enable NICHD to maintain the momentum and investments made with support
    provided through the Recovery Act. It will also enable the Institute to
    expand its support for preterm birth-related research and to initiate
    establishment of a network of integrated transdisciplinary research
    centers as recommended by the Institute of Medicine and the experts who
    participated in the Surgeon General's Conference. The causes of preterm
    birth are multi-factorial and necessitate a collaborative approach
    integrating many disciplines. These new centers would serve as a
    national resource for investigators to design and to share new research
    approaches and strategies to comprehensively address the problems of
    preterm birth.
    Centers for Disease Control and Prevention (CDC)--Preterm Birth
        The National Center for Chronic Disease Prevention and Health
    Promotion, Division of Reproductive Health works to promote optimal
    reproductive and infant health. In 2009, CDC created a robust research
    agenda to prevent preterm birth by improving National and State data to
    track preterm births; developing, implementing, and evaluating methods
    for prevention; understanding the problem of late preterm birth; and
    conducting etiologic and epidemiologic studies of early preterm birth.
    For fiscal year 2011, the March of Dimes recommends a $6 million
    increase in the preterm birth line to strengthen national data systems
    and to expand research on very early as well as late preterm births as
    authorized by the PREEMIE Act (Public Law 109-450).
    Centers for Disease Control and Prevention--National Center for Health
            Statistics
        The National Center for Health Statistics (NCHS) national vital
    statistics program collects birth data that is used to monitor the
    Nation's health status, set priorities and evaluate health programs. It
    is imperative that data collected by NCHS is comprehensive and timely.
    Currently, only 75 percent of States and territories use the 2003 birth
    certificate format and only 65 percent have adopted the 2003 death
    certificate. Consistent with the President's budget request, the
    Foundation recommends allocating $11 million specifically to the
    National Vital Statistics System to help support modernization of the
    State and territorial vital statistics infrastructure without
    undermining the scope and quality of data collected nationally.
    Health Resources and Services Administration--Healthy Start
        The Healthy Start Initiative is a collection of community-based
    projects focused on reducing infant mortality, low birthweight and
    racial disparities in perinatal outcomes. Communities with Healthy
    Start programs have seen significant improvements in health outcomes;
    therefore the March of Dimes recommends a funding level for these
    projects of $120 million in fiscal year 2011.

                                 BIRTH DEFECTS

        An estimated 120,000 infants in the United States are born with
    birth defects each year. Genetic or environmental factors, or a
    combination, can cause a birth defect; however, the causes of 70
    percent of birth defects remain unknown. Investing additional Federal
    resources in research to unveil the causes and prevent, or reduce, the
    incidence of birth defects is sorely needed.
    CDC National Center on Birth Defects and Developmental Disabilities
            (NCBDDD)
        The NCBDDD conducts programs to protect and improve the health of
    children by preventing birth defects and developmental disabilities and
    by promoting optimal development and wellness among children with
    disabilities. For fiscal year 2011, the March of Dimes requests an
    overall funding level of $163 million, a $20 million increase over
    fiscal year 2010, for NCBDDD. Within that increase, we encourage the
    committee to allocate $5 million for support of birth defects research
    and surveillance and an additional $2 million for folic acid education.
    This is a sound public health investment that will promote wellness and
    prevention, reduce health disparities, support the creation of new
    educational materials for consumers and their families and will enable
    CDC to better facilitate transition to adulthood for children with
    disabilities.
        Sustaining the investment in the National Birth Defects Prevention
    Study--the largest case-controlled study of birth defects ever
    conducted--is needed to support genetic analysis of the samples already
    obtained. In 2009, CDC educated healthcare providers through the
    dissemination of more than 10 reports which resulted from this Study.
    Among the topics were the risk factors for birth defects such as
    maternal smoking, obesity and antidepressant use during pregnancy.
        NCBDDD also supports State-based birth defects tracking systems and
    programs to prevent and treat affected children. Surveillance forms the
    backbone of a vital, functional and responsive public health network.
    Due to current the current fiscal crises being faced by many States,
    funding for some of these systems is in jeopardy. Increased investment
    from the Federal Government is necessary to ensure continued investment
    in birth defects surveillance programs.
        Finally, NCBDDD is conducting a national education campaign aimed
    at increasing the number of women consuming appropriate amounts of
    folic acid. CDC estimates that up to 70 percent of neural tube defects
    could be prevented if all women of childbearing age consume 400
    micrograms of folic acid daily. To achieve the full prevention
    potential of folic acid, CDC's national public and health professions
    education campaign must be expanded.

                               NEWBORN SCREENING

        Newborn screening is a vital public health activity used to
    identify and treat genetic, metabolic, hormonal and functional
    disorders in newborns. Screening detects conditions in newborns that,
    if left untreated, can cause disability, mental retardation, serious
    illness or even death. Across the Nation, State and local governments
    are experiencing significant budget shortfalls; due to this fiscal
    pressure, newborn screening programs are threatened by funding cuts.
    While the ramifications--such as discontinuing screening for certain
    conditions or postponing the purchase of necessary technology--can vary
    by State, any funding cut in this essential program puts infants at
    risk for permanent disability or even death. An additional $5 million
    for HRSA's heritable disorders program, as authorized by the Newborn
    Screening Saves Lives Act (Public Law 110-204), is necessary to
    increase support for State efforts to upgrade existing programs, to
    acquire state-of-the-art technology and to increase capacity to reach
    and educate health professionals and parents on newborn screening
    programs and follow-up services.

                                    CLOSING

        Thank you for the opportunity to testify on the federally supported
    programs of highest priority to the March of Dimes. The Foundation's
    volunteers and staff in every State, the District of Columbia and
    Puerto Rico look forward to working with Members of the Subcommittee to
    secure the resources needed to improve the health of the Nation's
    mothers, infants and children.

           MARCH OF DIMES FISCAL YEAR 2011 FEDERAL FUNDING PRIORITIES
                            [In millions if dollars]
    ------------------------------------------------------------------------
                                                Fiscal year   March of Dimes
                     Program                   2010 funding         rec
    ------------------------------------------------------------------------
    National Institutes of Health (Total)...      31,089          35,000
    National Children's Study...............         193.8           194.4
    Common Fund.............................         544             612
        National Institute of Child Health         1,329           1,495
         and Human Development..............
        National Human Genome Research               516             581
         Institute..........................
        National Center on Minority Health           212             239
         and Disparities....................
    Centers for Disease Control and                6,475           8,800
     Prevention (Total).....................
    Birth Defects Research & Surveillance...          21.342          26.342
    Folic Acid Campaign.....................           3.1             5.1
        Immunization........................         562             865.6
        Polio Eradication...................         102             102
        Preterm Birth.......................           2               8
    National Center for Health Statistics...         139             162
    Health Resources and Services                  7,483           9,150
     Administration (Total).................
        Maternal and Child Health Block              662             730
         Grant..............................
            Newborn Screening...............          10              15
        Newborn Hearing Screening...........          19              19
        Consolidated (Community) Health            2,146           2,560
         Centers............................
        Healthy Start.......................         105             120
    Agency for Healthcare Research and               397             611
     Quality................................
    ------------------------------------------------------------------------

                                     ______

             Prepared Statement of the Morehouse School of Medicine

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. John E.
    Maupin, president of Morehouse School of Medicine (MSM) in Atlanta,
    Georgia. I have previously served as president of Meharry Medical
    College, executive vice-president at MSM, as director of a community
    health center in Atlanta, and deputy director of health in Baltimore,
    Maryland. In all of these roles, I have seen firsthand the importance
    of minority health professions institutions and the Title VII Health
    Professions Training programs.
        I want to say that minority health professional institutions and
    the Title VII Health Professionals Training programs address a critical
    national need. Persistent and sever staffing shortages exist in a
    number of the health professions, and chronic shortages exist for all
    of the health professions in our Nation's most medically underserved
    communities. Furthermore, our Nation's health professions workforce
    does not accurately reflect the racial composition of our population.
    For example while blacks represent approximately 15 percent of the U.S.
    population, only 2-3 percent of the Nation's health professions
    workforce is black. Morehouse is a private school with a very public
    mission of educating students from traditionally underserved
    communities so that they will care for the underserved. Mr. Chairman, I
    would like to share with you how your subcommittee can help us continue
    our efforts to help provide quality health professionals and close our
    Nation's health disparity gap.
        There is a well-established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration, entitled ``The Rationale for Diversity in the Health
    Professions: A Review of the Evidence'' found that minority health
    professionals serve minority and other medically underserved
    populations at higher rates than nonminority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas; (2) provide care
    for minorities; and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution, and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        Given the historic mission, of institutions like MSM, to provide
    academic opportunities for minority and financially disadvantaged
    students, and healthcare to minority and financially disadvantaged
    patients, minority health professions institutions operate on narrow
    margins. The slow reinvestment in the Title VII Health Professions
    Training programs amounts to a loss of core funding at these
    institutions and have been financially devastating.
        Mr. Chairman, I feel like I can speak authoritatively on this issue
    because I received my dental degree from Meharry Medical College, a
    historically black medical and dental school in Nashville, Tennessee. I
    have seen first hand what title VII funds have done to minority serving
    institutions like Morehouse and Meharry. I compare my days as a student
    to my days as president, without that title VII, our institutions would
    not be here today. However, Mr. Chairman, since those funds have been
    slowly replenished, we are standing at a cross roads. This subcommittee
    has the power to decide if our institutions will go forward and thrive,
    or if we will continue to try to just survive. We want to work with you
    to eliminate health disparities and produce world class professionals,
    but we need your assistance.
        Minority Centers of Excellence (COE).--COEs focus on improving
    student recruitment and performance, improving curricula in cultural
    competence, facilitating research on minority health issues, and
    training students to provide health services to minority individuals.
    COEs were first established in recognition of the contribution made by
    four historically black health professions institutions (the Medical
    and Dental Institutions at Meharry Medical College; The College of
    Pharmacy at Xavier University; and the School of Veterinary Medicine at
    Tuskegee University) to the training of minorities in the health
    professions. Congress later went on to authorize the establishment of
    ``Hispanic'', ``Native American'' and ``Other'' Historically black
    COEs. For fiscal year 2011, I recommend a funding level of $33.6
    million for COEs.
        Health Careers Opportunity Program (HCOP).--HCOPs provide grants
    for minority and nonminority health profession institutions to support
    pipeline, preparatory, and recruiting activities that encourage
    minority and economically disadvantaged students to pursue careers in
    the health professions. Many HCOPs partner with colleges, high schools,
    and even elementary schools in order to identify and nurture promising
    students who demonstrate that they have the talent and potential to
    become a health professional. Over the last three decades, HCOPs have
    trained approximately 30,000 health professionals including 20,000
    doctors, 5,000 dentists and 3,000 public health workers. For fiscal
    year 2009, I recommend a funding level of $35.6 million for HCOPs.
    National Institutes of Health (NIH): Extramural Facilities Construction
        Mr. Chairman, if we are to take full advantage of the recent
    funding increases for biomedical research that Congress has provided to
    NIH over the past decade, it is critical that our Nation's research
    infrastructure remain strong. The current authorization level for the
    Extramural Facility Construction program at the National Center for
    Research Resources is $250 million. The law also includes a 25 percent
    set-aside for ``Institutions of Emerging Excellence'' (many of which
    are minority institutions) for funding up to $50 million. Finally, the
    law allows the NCRR Director to waive the matching requirement for
    institutions participating in the program. We strongly support all of
    these provisions of the authorizing legislation because they are
    necessary for our minority health professions training schools.
        There was 2-year funding in the stimulus bill for extramural
    facilities, but we need a sustained effort to help with our research
    and infrastructure enterprises. I ask that the fiscal year 2011 L-HHS
    bill include at least $50 million for this program.
        Research Centers in Minority Institutions (RCMI).--The RCMI program
    at the National Center for Research Resources has a long and
    distinguished record of helping our institutions develop the research
    infrastructure necessary to be leaders in the area of health
    disparities research. Although NIH has received unprecedented budget
    increases in recent years, funding for the RCMI program has not
    increased by the same rate. Therefore, the funding for this important
    program grow at the same rate as NIH overall in fiscal year 2011.
        Strengthening Historically Black Graduate Institutions--Department
    of Education.--The Department of Education's Strengthening Historically
    Black Graduate Institutions program (title III, part B, section 326) is
    extremely important to MMC and other minority serving health
    professions institutions. The funding from this program is used to
    enhance educational capabilities, establish and strengthen program
    development offices, initiate endowment campaigns, and support numerous
    other institutional development activities. In fiscal year 2011, an
    appropriation of $75 million is suggested to continue the vital support
    that this program provides to historically black graduate institutions.
        National Institute on Minority Health and Health Disparities
    (NIMHD).--The NIMHD is charged with addressing the longstanding health
    status gap between minority and nonminority populations. The NIMHD
    helps health professional institutions to narrow the health status gap
    by improving research capabilities through the continued development of
    faculty, labs, and other learning resources. The NIMHD also supports
    biomedical research focused on eliminating health disparities and
    develops a comprehensive plan for research on minority health at the
    NIH. Furthermore, the NIMHD provides financial support to health
    professions institutions that have a history and mission of serving
    minority and medically underserved communities through the Minority
    Centers of Excellence program. For fiscal year 2011, I recommend a
    funding level of $500 million for the NCMHD.
        Department of Health and Human Services' Office of Minority Health
    (OMH).--Specific programs at OMH include: (1) Assisting medically
    underserved communities with the greatest need in solving health
    disparities and attracting and retaining health professionals; (2)
    Assisting minority institutions in acquiring real property to expand
    their campuses and increase their capacity to train minorities for
    medical careers; (3) Supporting conferences for high school and
    undergraduate students to interest them in health careers; and (4)
    Supporting cooperative agreements with minority institutions for the
    purpose of strengthening their capacity to train more minorities in the
    health professions.
        The OMH has the potential to play a critical role in addressing
    health disparities, and with the proper funding this role can be
    enhanced. For fiscal year 2011, I recommend a funding level of $75
    million for the OMH.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    MSM along with other minority health professions institutions and the
    Title VII Health Professions Training programs can help this country to
    overcome health and healthcare disparities. Congress must be careful
    not to eliminate, paralyze, or stifle the institutions and programs
    that have been proven to work. MSM and other minority health
    professions schools seek to close the ever widening health disparity
    gap. If this subcommittee will give us the tools, we will continue to
    work towards the goal of eliminating that disparity as we have since
    our founding day.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

         Prepared Statement of the North American Brain Tumor Coalition

    National Institutes of Health (NIH)
        It is my pleasure as Chair of the North American Brain Tumor
    Coalition to submit this statement in favor of a strong Federal
    investment in biomedical research, an investment that is critically
    important to improving the treatments for brain tumors. For individuals
    with brain tumors, the possibility of surviving their diagnosis with a
    good quality of life depends on research and development of new
    treatments. Our recommendations to the subcommittee are intended to
    advance that research.
    The North American Brain Tumor Coalition and Its Members
        The North American Brain Tumor Coalition is a network of nine brain
    tumor organizations. Our members are the Brain Tumor Awareness
    Organization; Brain Tumour Foundation of Canada; Children's Brain Tumor
    Foundation; Florida Brain Tumor Association; Michael Quinlan Brain
    Tumor Foundation; National Brain Tumor Society; Preuss Foundation;
    Southeastern Brain Tumor Foundation; and Voices Against Brain Cancer.
        Many of the members of the Coalition raise private funds to support
    brain tumor research, while also undertaking patient and family support
    initiatives. Almost all of our members disseminate educational
    materials about brain tumors, and many also have forums for
    collaboration and cooperation among brain tumor researchers. The
    diversity of our organizations reflects the serious and far-reaching
    impact of brain tumors on patients and their families. We are pleased
    to have a Canadian organization in the Coalition, an important sign of
    international collaboration among brain tumor organizations. The fact
    that the Coalition includes organizations outside the United States is
    also a recognition of the fact that brain tumors respect no borders.
        The North American Brain Tumor Coalition brings these diverse
    organizations together to focus on advocacy on behalf of those with
    brain tumors. We are dedicated to improving the prognosis and quality
    of life for brain tumor patients. In order to achieve these goals,
    there must be an increased investment in research to understand the
    causes of brain tumors, improve brain tumor treatments, and strengthen
    neuro-rehabilitation services for those treated for brain tumors.
    Brain Tumors and Their Impact
        Brain tumors are not a single disease; there are approximately 126
    types of primary brain tumors. The diversity of brain tumors
    contributes to the complexity of research in this field. Many of the
    126 tumors classified as ``brain tumors'' are not in the brain but
    instead arise from structures that are associated with the brain. These
    include tumors of the membranes covering the brain (referred to as
    meningiomas) or adjacent cranial and paraspinal nerves (schwannomas).
    Brain tumors may be benign (most meningiomas are benign) to highly
    aggressive (glioblastomas). Both children and adults are diagnosed with
    brain tumors.
        It is estimated that there will be more than 62,000 cases of
    primary malignant and nonmalignant brain and central nervous system
    tumors in the United States in 2010.\1\ There will be approximately
    10,000 primary brain tumors in Canada in 2010. In 2010, it is estimated
    that 4,030 new primary brain tumors (malignant and nonmalignant) will
    be diagnosed in children in the United States in 2010. Of the 4,030 new
    cases, an estimated 2,880 will be in children under the age of 15.\1\
    ---------------------------------------------------------------------------
        \1\ Central Brain Tumor Registry, 2004-2006.
    ---------------------------------------------------------------------------
        Approximately 612,000 Americans are living with a primary brain
    tumor.\2\
    ---------------------------------------------------------------------------
        \2\ Porter KR, McCarthy BJ, Freels S, et al., Prevalence estimates
    for primary brain tumors in the US by age, gender, behavior, and
    histology. Neuro-Oncology, In press.
    ---------------------------------------------------------------------------
        The American Cancer Society estimates that almost 12,920 deaths in
    2009 will be attributed to primary malignant brain tumors.\3\ This
    total does not include those who will die from primary nonmalignant
    brain tumors.
    ---------------------------------------------------------------------------
        \3\ American Cancer Society, Cancer Facts & Figures 2009, Atlanta,
    2009.
    ---------------------------------------------------------------------------
        Many tens of thousands--140,000 or more--are diagnosed with
    metastatic brain tumors each year. Many tumor types can spread to the
    brain, but the most common are lung cancer, breast cancer, melanoma,
    kidney cancer, bladder cancer, and testicular cancer. It is estimated
    that metastatic brain tumors occur in 10 to 30 percent of adult
    cancers, and in one-fourth of all cancers that metastasize.\4\
    ---------------------------------------------------------------------------
        \4\ Medline Plus, National Library of Medicine, accessed on April
    7, 2010.
    ---------------------------------------------------------------------------
        These statistics about incidence, prevalence, and mortality are
    important, but they do not fully convey the burden of brain tumors. For
    many brain tumor patients, treatments are inadequate. Those who receive
    treatments that do extend their lives may nonetheless experience
    serious side-effects from their brain tumors and treatment, side-
    effects that require intervention. In addition, a diagnosis with a
    brain tumor does not only affect the patient; it also has a profound
    effect on the patient's family and friends.
        A study published in the Annals of Internal Medicine on April 6,
    2010, describes the impact of a cancer diagnosis on children. The study
    notes that there have been significant improvements in treatments for
    some pediatric cancers. However, cancer treatments often cause serious
    health problems, including but not limited to second cancers and heart
    conditions. The researchers used computer models to estimate what
    happens to childhood cancer survivors and determined that survivors of
    brain cancer died about 18 years earlier than the general population.
    This study underscores the problems confronted by brain tumor patients
    who ``survive'' their diagnosis.
    The Challenges of Brain Tumor Treatment and Research
        In a report dated 2000, the Brain Tumor Progress Review Group,
    convened by the National Cancer Institute (NCI) and National Institute
    of Neurological Disorders and Stroke (NINDS), stated that the
    difficulty in treating brain tumors relates to the unique biology of
    the brain, including the fact the brain is enclosed in a bony canal
    that allows little room for tumor growth, brain tumors invade normal
    tissue and make surgical removal impossible, brain tumors are protected
    by the blood-brain barrier, the brain is rich in expressed genes and
    therefore is a fertile field for growth of brain tumors, and brain
    tumors appear to be less susceptible to attack by the immune system
    than tumors in other organs.
        The complexity and diversity of brain tumors make the work of brain
    tumor researchers very difficult. For this reason, an aggressive and
    balanced approach to brain tumor research is necessary. The research
    effort must be strongly supported by NIH, as described below.
    NABTC Recommendations for NIH Funding
        The North American Brain Tumor Coalition supports the
    recommendations of many other biomedical research and patient advocacy
    organizations that NIH funding be increased to $35 billion in fiscal
    year 2011. This amount is necessary to sustain the commitment of the
    American Recovery and Reinvestment Act and prevent disruptions in the
    work of outstanding scientists committed to a wide range of research
    topics. The Coalition understands that this is a very aggressive
    recommendation in the current economic and budget climate, but this
    ambitious level of funding is necessary if additional advances in basic
    and applied science are to be achieved.
        A recent accomplishment in brain tumor research underscores the
    need for additional resources and a sustained Federal commitment in
    order to realize improvements in the quality of treatments for many
    diseases and quality of life for those who are diagnosed with those
    diseases. The Cancer Genome Atlas (TCGA) at NCI announced in January
    2010 that researchers in TCGA Research Network had determined that
    glioblastoma multiforme (GBM) is not a single disease but four distinct
    molecular subtypes. In announcing the research findings, TCGA said that
    the research might lead to a more personalized approach to GBM, one of
    the deadliest of all brain tumors.
        The North American Brain Tumor Coalition applauds the important
    research finding of TCGA but also notes that the finding points to the
    need for additional research, including:
      --Work to understand the molecular classification of other brain
            tumors, in addition to GBM;
      --Research to translate basic research findings into treatment
            approaches;
      --Identification of agents that might be evaluated in brain tumors,
            including those that are newly subject to a molecular
            classification scheme; and
      --Clinical testing of possible new agents for brain tumor treatment.
        In short, the findings of TCGA point the way to a new approach to
    brain tumor treatment, but we have only taken the first step in a long
    journey to effective, personalized brain tumor treatments.
        This translates to the need for a balanced research program that
    includes the following elements:
      --Support for investigator-initiated research so that new and
            promising ideas from the Nation's leading brain tumor
            researchers can be tested;
      --Funding for The Cancer Genome Atlas and other efforts that are
            advancing the molecular classification of disease;
      --Resources for translational programs to translate basic findings
            into new treatments; for brain tumor research, this means the
            continuation of the Specialized Programs of Research Excellence
            (SPOREs) and the adult and pediatric brain tumor consortia;
      --Support for clinical trials through the brain tumor consortia,
            cooperative groups, and cancer centers; and
      --Aggressive and creative support for research on the late and long-
            term effects of brain tumor treatment, including research on
            interventions for these side effects.
        We recommend that medulloblastoma be added to the list of cancers
    identified for further study through The Cancer Genome Atlas. We also
    encourage innovative strategies for data sharing in the SPORE program,
    including across SPORE sites. Research foundations and patient advocacy
    organizations are pioneering creative means for sharing clinical and
    research data, and we encourage NCI to consider some of these models
    for their applicability to SPORE sites and other research settings.
    NABTC Recommends Strategies for Encouraging Collaboration
        Brain tumor treatment is complex and multi-disciplinary, and
    research on these tumors must also have these characteristics. NCI and
    NINDS have established and supported a collaborative venture, the
    Neuro-Oncology Program, which takes a collaborative and cooperative
    approach to brain tumor research.
        This cooperative research approach is absolutely critical for brain
    tumors, but it will yield benefits for many other diseases as well. The
    Coalition applauds the leadership of the NIH Director in encouraging
    collaborative ventures that yield communication and collaboration among
    Institutes. We also recommend that more funding mechanisms be created
    to facilitate this sort of cooperation among academic research
    institutions seeking NIH funding.
    Urgency in the Brain Tumor Research Program
        It is necessary to keep a long view in biomedical research,
    sustaining funding levels and preventing disruptions in research.
    However, it is also important to have a sense of urgency about the pace
    of research. The 5-year relative survival rate for primary malignant
    brain tumors is 33.6 percent for males and 37 percent for females. For
    these individuals, time is precious and the research effort--literally
    their lifeline--must be accelerated as much as possible.
                                     ______

       Prepared Statement of the National Association of County and City
                                Health Officials

                                    SUMMARY

        The National Association of County and City Health Officials
    (NACCHO) represents the Nation's 2,800 local health departments (LHDs).
    These governmental agencies work every day in their communities to
    prevent disease, promote wellness, and protect the health of the entire
    community. 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 LHDs to play this
    role well.
        The Nation's current recession further diminishes the ability of
    LHDs to measure population-wide illness, organize efforts to prevent
    disease and prolong quality of life and to serve the public through
    programs not offered elsewhere. Repeated rounds of budget cuts and
    layoffs in LHDs continue to erode capacity. A series of NACCHO surveys
    found that in 2008-2009, 23,000 jobs have been lost in LHDs, which
    represents a 15 percent cut in the local public health workforce.
        LHDs continue to respond to increased challenges; including H1N1
    influenza, an increasing incidence of chronic disease and outbreaks of
    foodborne illness during a time of growing budget challenges. To help
    maintain the stability of LHDs, the Federal government should increase
    its investment in the following programs in fiscal year 2011
    appropriations: Public Health Emergency Preparedness, Advanced Practice
    Centers, Preventive Health and Health Services Block Grant, Healthy
    Communities and the Health Prevention Corps. Programs authorized by the
    health reform law should also be funded to the extent possible in
    fiscal year 2011 appropriations.
    Public Health Emergency Preparedness
        NACCHO Request.--$1.152 billion (including pandemic influenza
    preparedness).
        President's Budget Fiscal Year 2011.--$758 million (Public Health
    Emergency Preparedness).
        Emergency Supplemental Funds for H1N1 Influenza.--$1.3 billion.
        Fiscal Year 2010 Funding.--$761 million (Public Health Emergency
    Preparedness).
        The safety and well-being of America's communities is dependent on
    the capacity of their health departments to respond in any emergency
    that threatens human health, whether it is an act of bioterrorism, an
    influenza pandemic such as occurred in 2009-2010, or a natural
    disaster. The Centers for Disease Control and Prevention (CDC) has
    explicitly adopted an ``all-hazards'' approach to preparedness,
    recognizing that the capabilities necessary to respond to differing
    public health threats have many common elements.
        NACCHO requests $1.152 billion in funding for fiscal year 2011,
    which reflects continued funding for local and State preparedness
    activities under the Pandemic and All-Hazards Preparedness Act along
    with additional support necessary to sustain the capabilities that were
    put into place in 2009 to respond to the H1N1 flu epidemic, made
    possible through $1.3 billion in Federal emergency supplemental
    funding.
        With recent progress in nationwide preparedness and ongoing
    challenges, including the next flu season, now is not the time to
    reduce Federal funding that helps health departments continue their
    progress and address new, emerging threats. Especially when LHDs are
    under great stress from the loss of 15 percent of their workforce over
    the last 2 years, the Nation cannot afford to lose the gains made by
    recent Federal investment in public health. A loss of readiness is
    inevitable if the level of Federal investment is reduced.
        The enhanced capabilities enabled by pandemic influenza
    supplemental funding in 2009 will improve the response to other
    potential epidemics of infectious disease. At the same time, continuous
    training and exercising of all health department staff so that they are
    all ready for the next emergency must continue. Incorporating pandemic
    influenza preparedness into the context of all-hazards preparedness is
    the most efficient use of limited resources and will fully enable
    maintenance of the current level of preparedness and flexibility to
    alter priorities as needed when other public health threats emerge.
    Advanced Practice Centers
        NACCHO Request.--$5.4 million.
        President's Budget.--$5.3 million.
        Fiscal Year 2010 Funding.--$5.3 million.
        The mission of the Advanced Practice Center (APC) program is to
    promote innovative and practical solutions that enhance the
    capabilities of all LHDs to prepare for, respond to, and recover from
    public health emergencies. With locations in eight different geographic
    areas of the United States, the APC program supports and strengthens
    LHDs by developing and disseminating resources focused on helping them
    address gaps in local-level preparedness and improve responsiveness to
    address myriad health hazards. An increase in funding to $5.4 million
    would allow the tools produced through this program to reach more LHDs.
    Preventive Health and Health Services Block Grant
        NACCHO Request.--$131 million.
        President's Budget Fiscal Year 2011.--$102 million.
        Fiscal Year 2010 Funding.--$102 million.
        LHDs are leaders in efforts to stop preventable health threats from
    occurring. Obesity, heart attack, and accidental injury are all
    examples of preventable health problems LHDs work on every day. The
    Preventive Health and Health Services (PHHS) block grant program is a
    longstanding source of funding for these efforts.
        The increasing prevalence of costly and preventable chronic health
    conditions represents a threat to America's health and economy.
    According to the CDC, the medical care costs of people with chronic
    diseases account for more than 75 percent of the Nation's healthcare
    costs. The emerging epidemic of overweight and obesity is associated
    with $117 billion in annual direct medical expenses and indirect costs,
    including lost productivity, which impairs our economic competitiveness
    during a period of severe economic decline. Increased funding of $131
    million in fiscal year 2011 for the Preventive Health and Health
    Services Block Grant would allow local and State health departments to
    increase their efforts to focus on community priorities aimed at
    reversing the increase in preventable disease rates.
    Healthy Communities
        NACCHO Request.--$30 million.
        President's Budget Fiscal Year 2011.--$22.4 million.
        Fiscal Year 2010 Funding.--$22.8 million.
        The Healthy Communities program is dedicated to supporting local
    communities in implementing evidence-based interventions and policy,
    systems, and environmental changes necessary to help communities
    prevent chronic diseases and their risk factors.
        To reverse unfavorable trends in the prevalence and health
    consequences of chronic diseases, communities work in collaboration
    with LHD leadership to address such issues as affordable and accessible
    healthy food options, safe places for physical activity, and the need
    for targeted strategies that address and reduce health disparities.
    Changes in the local environment facilitate healthy choices and go hand
    in hand with education about how to be healthier.
        The Healthy Communities program mobilizes community leadership and
    resources to transform the local environments where people live, work
    and play to stem the growth of chronic disease. CDC anticipates the
    cumulative impact of the Healthy Communities program to reach more than
    300 communities by fiscal year 2011. With increased funding of $30
    million in fiscal year 2011, more communities can be reached with this
    innovative program.
    Health Prevention Corps
        NACCHO Request: $10 million.
        President's Budget.--$10 million.
        According to the President's budget, the Health Prevention Corps
    program will ``recruit new talent into service for State and LHDs and
    provide the building blocks for creating a stronger, interdisciplinary
    workforce.'' These funds are meant to create a foundation for the
    program by establishing a management plan for staffing and program
    administration, convening stakeholders to establish the program
    framework, and developing a curriculum for Corps members. A shortage of
    public health professionals is a constant challenge for LHDs and this
    program will help to build a supply of new personnel offering their
    talents and skills to local communities.

                     PROGRAMS ASSOCIATED WITH HEALTH REFORM

        The Patient Protection and Affordable Care Act authorized a number
    of new programs that will be beneficial to public health and LHDs. The
    health reform law provides an opportunity to focus on maintaining and
    creating health through support of community prevention programs. The
    law also includes programs that will help to strengthen the public
    health workforce which was challenged by shortages even prior to
    layoffs and attrition caused by recent budget cuts. Programs such as
    Public Health Loan Repayment and Mid-Career Training grants,
    Epidemiological and Laboratory Capacity Grants, Community
    Transformation Grants, Healthy Living, Aging Well and the Diabetes
    Prevention Program would fill tremendous needs at the local level and
    should be funded to the extent possible in the fiscal year 2011
    appropriations process.
                                     ______

     Prepared Statement of the National Association of Children's Hospitals

        On behalf of the National Association of Children's Hospitals
    (N.A.C.H.) and the Nation's free-standing children's hospitals, I
    respectfully request that the Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations Subcommittee provide the
    fully authorized funding level of $330 million for the Children's
    Hospitals Graduate Medical Education (CHGME) program in fiscal year
    2011.
        With the subcommittee's leadership, Congress has worked to provide
    equitable funding for the Nation's independent children's teaching
    hospitals through the CHGME program. An appropriation of $330 million
    would meet the program's authorization level and ensure that children's
    hospitals will receive equitable funding compared to the Federal
    support that other teaching hospitals receive through Medicare.
        In 2006, Congress reauthorized the CHGME program with nearly
    unanimous bipartisan support. Since then the Labor, Health and Human
    Services, and Education, and Related Agencies Appropriations
    Subcommittee has provided strong, consistent funding for CHGME. In
    fiscal year 2010, Congress appropriated the highest amount the program
    has ever received at $317.5 million. President Obama recognized the
    importance of CHGME in his fiscal year 2011 budget request and
    maintained funding at $317.5--$7.5 million above his request for fiscal
    year 2010.
        CHGME is a targeted, fiscally responsible, slow-growth program that
    is integral to ensuring a stable future for children's hospitals and
    the pediatric workforce. Congress created CHGME in 1999 because it
    recognized the importance of a well-trained pediatric workforce and
    understood the disparity in Federal graduate medical education (GME)
    support that existed between adult teaching hospitals and independent
    children's teaching hospitals. At that time, independent children's
    teaching hospitals were effectively left out of Federal GME support
    provided through Medicare because they treat children and not the
    elderly. In fact, children's hospitals were at a serious financial
    disadvantage, receiving less than 0.5 percent of the Federal GME
    support of other teaching hospitals. Medicaid GME payments, which are
    left to the discretion of States to provide and are well below the
    costs related to training, did not fill the gap.
        Congress also understood when it created CHGME that the disparity
    in GME support under Medicare jeopardized an already precarious
    pipeline of pediatric specialists. As a result of congressional
    foresight and commitment to this program, CHGME has played a critical
    role in addressing the Nation's serious shortage of pediatric
    specialists.
        Independent children's teaching hospitals, which represent less
    than 1 percent of all hospitals, train 35 of all general pediatric
    residents, half of all pediatric specialty fellows, the great majority
    of pediatric researchers, and many other physicians who require
    pediatric training. In addition, they provide half of all hospital care
    to seriously ill children and serve as the Nation's premier pediatric
    research centers.
        CHGME funding now provides children's hospitals with about 80
    percent of the GME support that Medicare provides to adult teaching
    hospitals. The funding has enabled children's hospitals to expand
    pediatric training programs, improve the quality and depth of their
    training, and prevent a net decline in the number of pediatric
    residents. Since the program's inception, children's hospitals have
    more than doubled the number of total pediatric specialty residents in
    response to local, regional, and national needs and children's
    hospitals have increased the number of new training programs by
    approximately 50 percent. These gains were achieved despite the cap on
    CHGME funds and caps on the number of full-time equivalent residents
    that could be counted for purposes of CHGME payment in accordance with
    Medicare rules.
        Unfortunately, shortages in the pediatric workforce still remain,
    particularly in pediatric specialty care. The National Association of
    Children's Hospitals and Related Institutions' (NACHRI) 2009 Pediatric
    Subspecialty Survey found a strong connection between pediatric
    specialty shortages, long-term vacancies and children's access to
    timely and appropriate healthcare. According to the survey, national
    shortages contribute to vacancies in children's hospitals that commonly
    last 12 months or longer for a number of pediatric specialties,
    including pediatric neurology, developmental-behavioral pediatrics,
    pediatric endocrinology, pediatric pulmonology, and pediatric
    gastroenterology.
        Sick children bear the brunt of the shortages of pediatric
    specialists. Wait times for scheduling appointments with pediatric
    specialists often exceeds the prevailing national benchmark of 2 weeks.
    In fact, at least half of children's hospital survey respondents
    reported wait times far longer than 2 weeks. For example:
      --68 percent of children's hospitals experience difficulty scheduling
            endocrinology visits; the average wait time is more than 10
            weeks;
      --61 percent report difficulty scheduling neurology visits; the
            average wait time is 9 weeks; and
      --50 percent report difficulty scheduling developmental pediatrics
            visits; the average wait time is more than 13 weeks. This
            exceptionally long wait time is of particular concern given the
            rise in autism-related disorders among the Nation's children.
        A January 2010 Wall Street Journal article, ``For Severely Ill
    Children, a Dearth of Doctors,'' put a human face on the NACHRI survey
    findings and described the impact of these shortages on a young patient
    and his family. ``Three-year old Kenneth Jones, for example, was born
    in Alaska with a rare gastrointestinal disorder that made him unable to
    absorb protein. He had to travel 3 hours to see one pediatric GI
    specialist in the state-a doctor who left a year later. The family
    moved to Oregon for work-related reasons and found a clinic that could
    provide complete care for the disorder--in Ohio, at a Cincinnati
    Children's Hospital clinic where they had to wait 7 months for
    Kenneth's first appointment. `There are so few pediatric GIs out there
    and so many children that need to be seen that you just have to wait in
    line,' says Kenneth's mother, Lauren Jones. `That's the hardest thing
    to endure for a parent with a sick child who needs help right away.' ''
        CHGME has allowed children's hospitals to begin to address the
    large gap that exists between families' need for pediatric specialty
    care and the supply. In fact, free-standing children's hospitals that
    receive CHGME funding have accounted for 65 percent of the growth in
    pediatric specialty programs.
        By strengthening children's hospitals' training programs and the
    Nation's pediatric workforce, CHGME benefits all children, not just
    those treated at independent children's teaching hospitals. CHGME funds
    indirectly strengthen children's hospitals' roles as pediatric centers
    for excellence, the safety net for low-income children, and the leading
    centers of pediatric research. Children's hospitals are at the center
    of scientific discovery as a result of their strong academic programs
    supported by CHGME and advanced life-saving clinical research.
    Children's teaching hospitals' scientific discoveries have helped
    children survive diseases that were once fatal, such as polio and
    cancer. Furthermore, as a result of scientific research breakthroughs
    at children's teaching hospitals, children now can grow and thrive with
    disabilities and chronic health conditions, such as congenital heart
    disease, cystic fibrosis, cerebral palsy, juvenile diabetes, and spina
    bifida, and become economically self-supporting adults and valuable
    members of their communities.
        CHGME is a sound investment. With full funding, CHGME will help to
    ensure a stable future for the Nation's children's hospitals and the
    pediatric workforce. With that support, children's hospitals will
    continue to be centers for excellence and be able to provide the
    highest-quality healthcare to all children.
        Once again, thank you for your past support for this critical
    program. On behalf of N.A.C.H., its member hospitals, and the children
    and families they serve, I respectfully ask you to provide $330 million
    for CHGME in fiscal year 2011 to support the continued progress that
    has been made in CHGME. As the Nation embarks on the implementation of
    the landmark health reform legislation, it is imperative that we have a
    strong pediatric workforce with a sufficient pool of specialists to
    meet the unique healthcare needs of all children.
                                     ______

      Prepared Statement of the National Association of Community Health
                                    Centers

                                  INTRODUCTION

        Chairman Harkin, Ranking Member Cochran, and members of the
    subcommittee: My name is Dan Hawkins, and I am the Senior Vice
    President of the National Association of Community Health Centers
    (CHC). On behalf of CHCs and the more than 20 million patients served
    nationwide, as well as the volunteer board members, staff, and
    countless members of the health center movement, I want to thank you
    for this subcommittee's unyielding support for health centers and your
    dedication to the health center mission of providing affordable,
    accessible primary healthcare to all Americans.
        As you know, Congress recently passed the Patient Protection and
    Affordable Care Act (Affordable Care Act)--a law that is historic by
    any measure. The law endeavors to ensure that for the first time, all
    Americans will have access to quality healthcare. From the community
    health center perspective, we are incredibly humbled at the charge the
    new law gives to health centers: to become the healthcare home for
    millions of newly insured patients, even as we maintain our high
    standards of openness to all and a focus on achieving quality that is
    second to none.
        Health centers were started 45 years ago because their founders
    knew that an urgent intervention was needed to deal with the crisis of
    access in America. Today, health centers have been called upon again,
    this time to expand our proven system of care rapidly to ensure that as
    our nation extends coverage to millions of Americans, the promise of
    coverage truly equals care. With your continued support, health centers
    stand ready to deliver and to reach the goals that Congress has set
    out: providing care to 40 million Americans by 2015.
    About CHCs
        Today, health centers serve more than 20 million patients in nearly
    8,000 communities. Health centers serve as the family doctor and
    healthcare home for 1 in 8 uninsured individuals, and 1 in every 5 low-
    income children.
        Federal law requires that every health center be governed by a
    patient-majority board, which means care is truly patient-centered and
    patient-driven. Health centers must be located in a designated
    Medically Underserved Area, and must provide comprehensive primary care
    services to anyone who comes in the door, regardless of ability to pay.
        As health leaders as well as providers in their communities, health
    centers believe that they have an obligation to work to prevent disease
    and improve the lives and health of their patients and their
    communities. For this reason, health centers have been pioneers in
    improving healthcare quality, particularly in the area of chronic
    disease management. Through the Health Resources and Services
    Administration's Health Disparities Collaboratives, the majority of
    health centers have worked to improve their delivery systems and to
    more effectively educate patients on the self-management of their
    conditions such as cancer, diabetes, asthma, and cardiovascular
    disease. Health centers participating in the Collaboratives almost
    unanimously report that health outcomes for their patients have
    dramatically improved. Published studies have documented these
    outcomes, including one study on the Diabetes Collaboratives where
    evidence showed that over a lifetime, the incidence of blindness,
    kidney failure, and coronary artery disease was reduced.\1\
    ---------------------------------------------------------------------------
        \1\ Huang, E, Zhang, Q, Brown, S. E.S., Drum, M, Meltzer, D, Chin,
    M. (2007). The Cost-Effectiveness of Improving Diabetes Care in U.S.
    federal Qualified Community Health Centers. Health Services Research,
    42, (6p1), 2174-2193.
    ---------------------------------------------------------------------------
        Health centers not only improve health and save lives, they also
    cost significantly less, saving the health system overall. In South
    Carolina, a study showed that diabetic patients enrolled in the State
    employees' health plan treated in non-CHC settings were four times more
    costly than those in the same plan who were treated in a community
    health center. The health center patients also had lower rates of
    emergency room use and hospitalization.\2\ In fact, literally dozens of
    studies done over the past 25 years, have concluded that health center
    patients are significantly less likely to use hospital emergency rooms
    or to be hospitalized for ambulatory care-sensitive conditions, and are
    therefore less expensive to treat than patients treated elsewhere.\3\ A
    recent national study done in collaboration with the Robert Graham
    Center found that people who use health centers as their usual source
    of care have 41 percent lower total healthcare expenditures than people
    who get most of their care elsewhere.\4\ As a result, health centers
    saved the healthcare system $18 billion last year alone.
    ---------------------------------------------------------------------------
        \2\ Proser M. ``Deserving the Spotlight: Health Centers Provide
    High-Quality and Cost-Effective Care.'' October-December 2005 Journal
    of Ambulatory Care Management 28(4):321-330.
        \3\ Rust G., et al. ``Presence of a Community Health Center and
    Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal
    of Rural Health, Winter 2009 25(1):8-16; Dobson D, et al. ``The
    Economic and Clinical Impact of Community Health Centers in Washington
    State: Analyses of the Contributions to Public Health and Economic
    Implications and Benefits for the State and Counties.'' Dec 2008
    Community Health Network of Washington and Washington Association of
    Community and Migrant Health Centers; McRae T. and Stampfly R. ``An
    Evaluation of the Cost Effectiveness of Federal Qualified Health
    Centers (FQHCs) Operating in Michigan.'' October 2006 Institute for
    Health Care Studies at Michigan State University. www.mpca.net. Falik
    M, Needleman J, Herbert R, et al. ``Comparative Effectiveness of Health
    Centers as Regular Source of Care.'' January-March 2006 Journal of
    Ambulatory Care Management 29(1):24-35; Proser M. ``Deserving the
    Spotlight: Health Centers Provide High-Quality and Cost-Effective
    Care.'' October-December 2005 Journal of Ambulatory Care Management
    28(4):321-330; Politzer RM, et al. ``The Future Role of Health Centers
    in Improving National Health.'' 2003 Journal of Public Health Policy
    24(3/4):296-306; see also, e.g., Politzer RM, et al. ``Inequality in
    America: The Contribution of Health Centers in Reducing and Eliminating
    Disparities in Access to Care.'' 2001 Medical Care Research and Review
    58(2):234-248; Falik M, et al. ``Ambulatory Care Sensitive
    Hospitalizations and Emergency Visits: Experiences of Medicaid Patients
    Using Federal Qualified Health Centers.'' 2001 Medical Care 39(6):551-
    56; Starfield, Barbara, et al, ``Costs vs. Quality in Different Types
    of Primary Care Settings,'' Journal of the American Medical Association
    272,24 (December 28, 1994): 1903-1908; Stuart, Mary E., et al,
    ``Improving Medicaid Pediatric Care,'' Journal of Public Health
    Management Practice 1(2) (Spring, 1995): 31-38; Utilization and Costs
    to Medicaid of AFDC Recipients in New York Served and Not Served by
    Community Health Centers, Center for Health Policy Studies (1994);
    Stuart, Mary E., and Steinwachs, Donald M., (Johns Hopkins Univ. School
    of Public Health and Hygiene), ``Patient-Mix Differences Among
    Ambulatory Providers and Their Effects on Utilization and Payments for
    Maryland Medicaid Users,'' Medical Care 34,12 (December 1993): 1119-
    1137; Health Services Utilization and Costs to Medicaid of AFDC
    Recipients in California Served and Not Served by Community Health
    Centers, Center for Health Policy Studies/SysteMetrics (1993).
        \4\ NACHC and the Robert Graham Center. Access Granted: The Primary
    Care Payoff. August 2007. www.nachc.com/access-reports.cfm.
    ---------------------------------------------------------------------------
    Funding Background
        Over the last decade, this subcommittee has been at the forefront
    of expanding access to primary care in America and changing the way
    primary care is delivered through its expansion of the Health Centers
    Program. This expansion effort brought access to care to millions who
    were previously medically disenfranchised. Since 2001, this
    subcommittee has nearly doubled the investment in the Health Centers
    program. In that time, more than 3,500 new health center sites have
    been created, and more than 10 million new patients have gained access
    to care in a health center. It is your commitment that has proven what
    we in the health centers movement knew to be true: that our patient-
    centered, community-based health center model of care is the best way
    for Americans to receive primary care.
    Impact of Health Reform
        The passage of comprehensive health reform builds on this
    subcommittee's efforts by envisioning yet another expansion of the
    Health Centers Program over the next 5 years. The law creates a
    Community Health Center Fund containing $11 billion in new funding for
    health centers over the next 5 years. We believe this funding will
    allow health centers to grow to serve 40 million Americans by the end
    of fiscal year 2015. This investment will ensure that as more Americans
    become insured, they will actually have a healthcare home in their
    community in which to access care.
    Fiscal Year 2011 Request
        The CHC Fund has the potential to fundamentally and positively
    change the way primary care is delivered in this country. However, in
    order for the CHC Fund to have its intended impact, it is critical that
    the discretionary funding level of the Health Centers Program at least
    meet the fiscal year 2010 level of $2.19 billion. Keeping the
    discretionary funding base at least at the fiscal year 2010 level will
    allow the CHC Fund to be fully utilized for new health centers,
    expanded medical, oral, behavioral, and pharmacy services at existing
    health centers, and allow the continuation of desperately needed ARRA
    Increased Demand for Services funding to health centers who have
    already expanded care to almost 2 million new patients over the last
    year.
    Conclusion
        At this historic moment for the health centers movement, I am
    deeply proud to be speaking for CHCs nationwide. I have personally seen
    the power of health centers to lift the health and the lives of
    individuals and families in our most underserved communities. Thanks to
    your longstanding support, health centers have revolutionized primary
    care community by community and we are ready to do even more. In light
    of the passage of health reform, health centers stand ready to live up
    to the incredible trust that has been placed in us. With your support,
    we look forward to ensuring that the Government's investment in reform
    translates into improved health and wellness for the Nation for years
    to come.
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research

                               EXECUTIVE SUMMARY

        National Alliance for Eye and Vision Research (NAEVR) requests
    fiscal year 2011 National Institutes of Health (NIH) funding at $35
    billion, which reflects a $3 billion increase more than President
    Obama's proposed funding level of $32 billion. Funding at $35 billion,
    which reflects NIH's net funding levels in both fiscal year 2009 and
    fiscal year 2010, ensures it can maintain the number of multi-year
    investigator-initiated research grants, the cornerstone of our Nation's
    biomedical research enterprise.
        The vision community commends Congress for $10.4 billion in NIH
    funding in the American Recovery and Reinvestment Act (ARRA), as well
    as fiscal year 2009 and fiscal year 2010 funding increases that enabled
    NIH to keep pace with biomedical inflation after 6 previous years of
    flat funding that resulted in a 14 percent loss of purchasing power.
    Fiscal year 2011 NIH funding at $35 billion enables it to meet the
    expanded capacity for research--as demonstrated by the significant
    number of high-quality grant applications submitted in response to ARRA
    opportunities--and to adequately address unmet need, especially for
    programs of special promise that could reap substantial downstream
    benefits, as identified by NIH Director Francis Collins, M.D., Ph.D. in
    his top five priorities. As President Obama has stated repeatedly,
    including at a visit to the NIH in September 2009, biomedical research
    has the potential to reduce healthcare costs, increase productivity,
    and ensure the global competitiveness of the United States.
        NAEVR requests that Congress improve upon the President's proposed
    2.5 percent National Eye Instutute (NEI) increase--the second smallest
    increase of all Institutes and Centers--especially if it does not
    increase overall NIH funding above the President's request.
        In 2009, Congress spoke volumes in passing S. Res. 209 and H. Res.
    366, which acknowledged NEI's 40th anniversary and designated 2010-2020
    as The Decade of Vision, in which the majority of 78 million Baby
    Boomers will turn 65 years of age and face greatest risk of aging eye
    disease. This is not the time for a less-than-inflationary increase
    that nets a loss in the NEI's purchasing power, which eroded by 18
    percent in the fiscal year 2003-2008 timeframe. NEI-funded research is
    resulting in treatments and therapies that save vision and restore
    sight, which can reduce healthcare costs, maintain productivity, ensure
    independence, and enhance quality of life.

     FISCAL YEAR 2011 NIH FUNDING AT $35 BILLION ENABLES THE NEI TO BUILD
    UPON THE IMPRESSIVE RECORD OF BASIC AND CLINICAL COLLABORATIVE RESEARCH
    THAT MEETS NIH'S TOP FIVE PRIORITIES AND WAS FUNDED THROUGH FISCAL YEAR
            2009-2010 ARRA AND INCREASED ``REGULAR'' APPROPRIATIONS

        NEI's research addresses the pre-emption, prediction, and
    prevention of eye disease through basic, translational,
    epidemiological, and comparative effectiveness research which also
    address the top five NIH priorities, as identified by Dr. Collins:
    genomics, translational research; comparative effectiveness; global
    health, and empowering the biomedical enterprise. NEI continues to be a
    leader within the NIH in elucidating the genetic basis of ocular
    disease--NEI Director Paul Sieving, M.D., Ph.D., has reported that one-
    quarter of all genes identified to date through collaborative efforts
    with the National Human Genome Research Institute (NHGRI) are
    associated with eye disease/visual impairment.
        NEI received $175 million of the $10.4 billion in NIH ARRA funding.
    As a result, NEI's total funding levels in the fiscal year 2009-2010
    timeframe were $776 million and $794.5 million, respectively. In fiscal
    year 2009, NEI made 333 ARRA-related awards, the majority of which
    reflect investigator-initiated research that funds new science or
    accelerates ongoing research, including ten Challenge Grants. Several
    examples of research, and the reasons why it is important, include:
      --Biomarker for Neovascular Age-related Macular Degeneration (AMD).--
            Researchers will use a recently discovered biomarker for
            choroidal neovascularization--the growth of abnormal blood
            vessels into the retina and responsible for 90 percent of
            vision loss associated with AMD--to develop an early detection
            method to minimize vision loss. Why important? AMD is the
            leading cause of vision loss in the United States, especially
            in the elderly.
      --Cellular Approach to Treating Diabetic Retinopathy (DR).--
            Researchers propose to develop a clinical treatment for
            diabetic retinopathy--in which diabetes damages small blood
            vessels in the retina, causing them to leak--that uses stem
            cells from the patient's own blood that have been activated
            outside of the body and then returned to repair damaged vessels
            in the eye. Why important? DR is the leading cause of vision
            loss in younger Americans, and its incidence is
            disproportionately higher in African Americans, Latinos, and
            Native Americans.
      --Small Heat Shock Proteins as Therapeutic Agents in the Eye.--
            Researchers propose to develop new drugs to prevent or reverse
            blinding eye diseases, such as cataract (clouding of the lens),
            that are associated with the aggregation of proteins. Research
            will focus on the use of small ``heat shock'' proteins that
            facilitate the slow release and prolonged delivery of targeted
            macromolecules to degenerating cells of the eye. Why important?
            Delivering effective, long-lasting therapies through a
            minimally invasive route into the eye is a major challenge.
      --Identification of Genes and Proteins That Control Myopia
            Development.--Researchers propose to identify targets that will
            facilitate development of interventions to slow or prevent
            myopia (nearsightedness) development in children. Identifying
            an appropriate myopia prevention target can reduce the risk of
            blindness and reduce annual life-long eye care costs. Why
            important? More than 25 percent of the U.S. population has
            myopia, costing $14 billion annually, from adolescence to
            adulthood.
      --Comparison of Interventions for Retinopathy of Prematurity (ROP).--
            In animal studies, researchers will simulate Retinopathy of
            Prematurity--a blinding eye disease that affects premature
            infants--and then study novel treatments that involve
            modulating the metabolism of the retina's rod photoreceptors.
            Why important? ROP affects 15,000 children a year, about 400-
            600 of whom progress to blindness, at an estimated lifetime
            cost for support and unpaid taxes of $1 million each.
      --The NEI Glaucoma Human genetics collaBORation, NEIGHBOR.--This
            research network, in which seven U.S. teams will lead genetic
            studies of the disease, may lead to more effective diagnosis
            and treatment. Researchers were primarily funded through ARRA
            supplements. Why important: Glaucoma, a complex
            neurodegenerative disease that is the second leading cause of
            preventable blindness in the United States, often has no
            symptoms until vision is lost.
      --Comparative Effectiveness of Interventions for Primary Open Angle
            Glaucoma (POAG).--Researchers will evaluate existing data on
            the effectiveness of various treatment options for primary open
            angle glaucoma--many emerging from past NEI research. Why
            important? POAG is the most common form of the disease, which
            disproportionately affects African Americans and Latinos.
        In addition to ARRA funding, the ``regular'' appropriations
    increases in fiscal year 2009-2010 enabled the NEI to continue to fund
    key research networks, such as the following:
      --The African Descent and Glaucoma Evaluation Study (ADAGES), which
            is designed to identify factors accounting for differences in
            glaucoma onset and rate of progression between individuals of
            African and European descent.
      --The Diabetic Research Clinical Research Network's initiation of new
            trials comparing the safety and efficacy of drug therapies as
            an alternative to laser treatment for diabetic macular edema
            and proliferative diabetic retinopathy.
      --The Neuro-Ophthalmology Research Disease Investigator Consortium
            (NORDIC), which will lead multi-site observational and
            treatment trials, involving nearly 200 community and academic
            practitioners, to address the risks, diagnosis, and treatment
            of visual dysfunction due to increased intracranial pressure
            and thyroid eye disease.
        The unprecedented level of fiscal year 2009-2010 vision research
    funding is moving our Nation that much closer to the prevention of
    blindness and restoration of vision. With an overall NIH funding level
    of $35 billion, which translates to an NEI funding level of $794.5
    million, the vision community can accelerate these efforts, thereby
    reducing healthcare costs, maintaining productivity, ensuring
    independence, and enhancing quality of life.
     if congress does not increase fiscal year 2011 nih funding above the
    president's request, it is even more vital to improve upon the proposed

                          2.5 PERCENT INCREASE FOR NEI

        The NIH budget proposed by the administration and developed by
    Congress during the very first year of the Congressionally-designated
    Decade of Vision should not contain a less-than-inflationary increase
    for the NEI due to the enormous challenges it faces in terms of the
    aging population, the disproportionate incidence of eye disease in
    fast-growing minority populations, and the visual impact of chronic
    disease (e.g., diabetes). If Congress is unable to fund NIH at $35
    billion in fiscal year 2011 (NEI level of $794.5 million) and adopts
    the President's proposal, the 2.5 percent increase in funding must be
    increased to at least an inflationary level of 3.2 percent to prevent
    any further erosion in NEI's purchasing power. NEI funding is an
    especially vital investment in the overall health, as well as the
    vision health, of our Nation. It can ultimately delay, save, and
    prevent health expenditures, especially those associated with the
    Medicare and Medicaid programs, and is, therefore, a cost-effective
    investment.

      VISION LOSS IS A MAJOR PUBLIC HEALTH PROBLEM: INCREASING HEALTHCARE
             COSTS, REDUCING PRODUCTIVITY, DIMINISHING LIFE QUALITY

        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.

                                  ABOUT NAEVR

        The National Alliance for Eye and Vision Research (NAEVR) is a
    501(c)4 nonprofit advocacy coalition comprised of 55 professional,
    consumer, and industry organizations involved in eye and vision
    research. Visit NAEVR's Web site at www.eyeresearch.org.
                                     ______

       Prepared Statement of the National Association of Local Boards of
                                     Health

        We strongly urge you to consider funding in the area of Public
    Health Systems and Services Research (PHSSR). This is an emerging field
    that is experiencing rapid growth. Research in this area is in its
    infancy with tremendous potential to grow as a field of study, while at
    the same time is of great benefit to the public. The National
    Association of Local Boards of Health (NALBOH) has both contributed to
    and benefited from research in PHSSR along with forming collaborative
    partnerships with organizations having similar interests, thereby
    complimenting and building on the work of others such as the National
    Association of County and City Health Officials (NACCHO) and the
    Association of State and Territorial Health Officials (ASTHO).
        Specifically, one of these collaborative efforts has been the data
    harmonization project. Through this project, a large, collective
    database is being formed that researchers, boards of health, health
    departments and the public can use when developing educational
    materials and resources, fostering partnerships, and making more
    streamlined efforts to advance public health at the local level.
    Members of local boards of health are leaders on which their
    communities, cities, and counties rely; therefore it is critical to
    ensure that board members have adequate training and resources
    available to them so they can fulfill the duties of their positions,
    making evidence-based decisions.
        One way that we can assess the needs of boards is through the
    NALBOH profile survey. A web-based survey will be conducted in 2010
    extending a mail survey that was conducted in 2008. This survey
    provides a voice for the more than 3,200 local boards of health
    encompassing more than 20,000 members nationwide. The information
    gathered through this survey and similar projects conducted by NALBOH
    and its collaborators demonstrates areas in which local boards of
    health need training, provides a description of the duties and
    responsibilities of these boards, and supplies a description of the
    member demographic composition of these boards.
        Additionally, NALBOH has on-going Public Health Systems and
    Services Research projects. One project is conducting a survey of state
    boards of health to provide a description of these boards and their
    duties. This survey will help to fill a void of such data. Other
    projects include assessing the processes by which board of health
    members are appointed. A more thorough understanding of this process
    will allow NALBOH and its partners to assist in ensuring that the best
    interests of the public are served as board of health members are
    appointed. Governance legal authority of local boards of health is
    being explored to determine whether local board of health members
    understand their statutory authority, how they perceive this authority,
    and how this is related to their board's effectiveness.
        We urge you to provide financial support for these valuable
    programs.
                                     ______

         Prepared Statement of the National Alliance on Mental Illness

        Chairman Harkin and members of the subcommittee, I am Mike
    Fitzpatrick, Executive Director of the National Alliance on Mental
    Illness (NAMI). I am pleased today to offer NAMI's views on the
    subcommittee's upcoming fiscal year 2011 bill. NAMI is the Nation's
    largest grassroots advocacy organization representing persons living
    with serious mental illnesses and their families. Through our 1,100
    affiliates in all 50 States, we support education, outreach, advocacy
    and research on behalf of persons with serious mental illnesses such as
    schizophrenia, manic depressive illness, major depression, severe
    anxiety disorders, and major mental illnesses affecting children.
        The cost of mental illness to our Nation is enormous. It is
    estimated that the direct and indirect cost of untreated mental illness
    to our Nation exceeds $80 billion annually. However, these direct and
    indirect costs do not measure the substantial and growing burden that
    is imposed on ``default'' systems that are too often responsible for
    serving children and adults with mental illness who lack access to
    treatment. These costs fall most heavily on the criminal justice and
    corrections systems, emergency rooms, schools, families, and homeless
    shelters. Moreover, these costs are not only financial, but also human
    in terms of lost productivity, lives lost to suicide and broken
    families. Investment in mental illness research and services are--in
    NAMI's view--the highest priority for our Nation and this subcommittee.
    National Institute of Mental Health (NIMH) Research Funding
        NIMH is the principal Federal agency charged with funding
    biomedical research on serious mental illnesses. To inspire and support
    research that will continue to make a difference for people living with
    mental illnesses, and ultimately, promote recovery, NIMH developed a
    strategic plan in 2009 to guide future research efforts. The
    overarching objectives of the strategic plan are to: (1) promote
    discovery in the brain and behavioral sciences to fuel research on the
    causes of mental disorders; (2) chart mental illness trajectories to
    determine when, where and how to intervene; (3) develop new and better
    interventions that incorporate the diverse needs and circumstances of
    people with mental illnesses; and (4) strengthen the public health
    impact of NIMH-supported research.
    Translating Research Advances into New Treatments
        It is critical for us to move beyond the current universe of
    palliative treatments for serious mental illness. Even with optimal
    care, some children and adults living with serious mental illness will
    not be able to achieve recovery (as defined as permanent remission). As
    NIMH Director Dr. Tom Insel has noted, consumers and families need
    rapid, effective treatments that target the core pathophysiology of
    serious mental illnesses and the tools for early detection. Mental
    illness research can develop new diagnostic markers and treatments, but
    this will require defining the pathophysiology of these illnesses. NIMH
    now has the research tools necessary. Now is the time to set an
    ambitious goal of finding cures to these extremely disabling illnesses.
    However, NIMH must have the resources it needs to support this critical
    research agenda.
    American Recovery and Reinvestment Act (ARRA) Investments
        NAMI would like to draw the subcommittee's attention to two
    specific critical investments NIMH is making as part of the ARRA and
    collaborations with the Department of Defense. The first is the
    Recovery After an Initial Schizophrenia Episode (RAISE) study which is
    being financed (in part) with $368 million in ARRA funds. RAISE is the
    first ever large-scale trial exploring early and aggressive treatment
    integrating a variety of different therapies to reduce the symptoms and
    prevent the gradual deterioration of functioning that is characteristic
    in schizophrenia. The second is Study to Assess Risk and Resilience in
    Service Members (STARRS)--a joint Army-NIMH study of suicide and mental
    health among military personnel. Army STARRS will identify--as rapidly
    as possible--modifiable risk and protective factors related to mental
    health and suicide. It also will support the Army's ongoing efforts to
    prevent suicide and improve soldiers' overall well being.
    Continuing the Federal Investment in Mental Illness Research
        The President is proposing $1.541 billion for basic scientific and
    clinical research at the NIMH. This is a $51 million increase above the
    current fiscal year 2010 level of $1.489 billion. While this is below
    the expected increase in biomedical research inflation, it is a
    tremendous accomplishment and endorsement of the importance of
    investment in medical research in a budget that proposes an overall
    freeze in domestic discretionary spending.
        For fiscal year 2011, NAMI supports the recommendations of the Ad
    Hoc Group on Medical Research for an overall NIH funding level of $36
    billion (a 12 percent increase more than fiscal year 2010). For NIMH,
    NAMI recommends a similar 12 percent increase, up to $1.683 billion--
    $143 million above the President's request and $193.6 million above the
    fiscal year 2010 appropriation.
    Funding for Programs at SAMHSA's Center for Mental Health Services
            (CMHS)
        Mr. Chairman, as our Nation continues to struggle through this
    current economic downturn and States struggle with diminished revenues,
    we are experiencing unprecedented strain in mental health service
    budgets. Since 2009, we have seen a combined total of nearly $1.8
    billion cut from State mental health authority (SMHA) budgets. In a
    number of States the spending reduction for mental health exceeds 20
    percent of the entire SMHA budget. A few examples of the scale of these
    cuts to State mental health budgets include:
      --Ohio.--Combined State mental health authority cuts from 2009
            through 2011 of 36.2 percent across the board or a $191.3
            million reduction.
      --Rhode Island.--A total percentage cut of 34 percent from 2007 to
            2009 (from a statewide budget of $82.1 million to $54.5
            million)--as a result the State is experiencing a 65 percent
            increase in the number of children with Serious Emotional
            Disturbance boarding in public emergency rooms.
      --Illinois.--Since 2009, 10,000 low-income children and adults have
            lost access to community-based mental healthcare.
      --Kansas.--New admissions to the State's public psychiatric hospitals
            have been frozen for the remainder of 2010 and nine of the
            State's 27 Community Mental Health Centers are in operating
            deficits and in jeopardy of being closed (most of these
            agencies serve rural health professional shortage areas).
      --Mississippi.--The Governor has proposed an $18 million cut this
            year that would result in the closing of six crisis centers and
            four Department of Mental Health facilities including two
            inpatient psychiatric hospitals.
        When investments in treatment, support and recovery are slashed to
    this extreme degree, the costs to society and to Government do not go
    away. Instead, the costs just get passed along far more expensively in
    terms of public spending and far less successfully in terms public
    health:
      --Half of all lifetime mental illnesses begin by age 14 and without
            access to early diagnosis and treatment, we end up paying much
            more for special education, private placements, substance abuse
            and juvenile detention.
      --Without access to community-based treatment and support, we end up
            paying much more for secondary medical symptoms, homelessness,
            addiction, broken families, extended hospital emergency
            admissions, nursing home beds, jails, and prisons.
      --Without access to mental healthcare, our national and State
            economies lose billions of dollars every year in unemployment,
            under-employment and lost productivity.
      --Without access to treatment and recovery, people with serious
            mental illnesses are destined to die 25 years sooner than the
            general population.
        At NAMI we refer to this as ``spending money in all the wrong
    places'' as the burden of untreated mental illness is shifted and
    hidden but no less at taxpayers expense.
        It is imperative that programs at the Center for Mental Health
    Services (CMHS) at SAMHSA help States respond to the individual crises
    they are facing in trying to manage such deep reductions to community
    mental health budgets in a time of rising demand--both respect to the
    needs of the existing population of people living with serious mental
    illness and new populations at risk of anxiety, depression and
    psychosis.
        In particular, this subcommittee must expand investment in the
    Mental Health Block Grant (MHBG) for fiscal year 2011. Funding for the
    MHBG has been frozen at its current level of $420 million since fiscal
    year 2000. NAMI urges the subcommittee to respond to this crisis at the
    State level by increasing funding for the Mental Health Block Grant by
    $100 million to $520 million in fiscal year 2011.
        NAMI would also recommend the following priorities for CMHS for
    fiscal year 2011:
      --Support the President's proposal to increase the PATH Homeless
            Formula Grant program to $70 million (a proposed $5 million
            increase above fiscal year 2010),
      --Support the President's proposal for a $5 million increase for the
            Children's Mental Health program, boosting funding up to $126
            million, and
      --Support the President's proposal for a $6 million increase for
            suicide prevention activities at CMHS (up to $54.2 million),
            including funding for the Garrett Lee Smith Memorial Act.
    Addressing Chronic Homelessness and Mental Illness
        SAMHSA's homeless programs fill a gap created by a preference for
    funding housing capital needs over the critically important services
    that are necessary for programs to be effective. In the recent
    competition conducted by SAMHSA the agency received more than 500
    qualified applications, of which the agency was only able to fund 68.
    The interest and capacity of providers to put these Federal dollars to
    work and end homelessness for thousands of homeless individuals should
    demonstrate to Congress a clear mandate to significantly increase
    funding for SAMHSA's homeless programs.
        The current fiscal year 2010 funding level of SAMHSA homeless
    programs is $75 million. This is divided between two accounts: $32.25
    million within the Center for Mental Health Services (CMHS) and $42.75
    within the Center for Substance Abuse Treatment (CSAT). The President's
    budget proposes an increase of $12.1 million, $7.446 million for CMHS
    and $4.610 million for CSAT.
        The President's 2011 budget proposal includes a new Homeless
    Initiative Program. This is a HUD/HHS partnership creating two
    demonstration programs, including one that couples Housing Choice
    Vouchers with services funding by Medicaid and SAMHSA. The Medicaid
    funds are mandatory spending and do not require an appropriations
    amount. However, the SAMHSA contribution must be appropriated and the
    President proposes $15.8 million. This funding includes the $12.1
    million proposed SAMHSA homeless services increase and an additional
    $3.7 million from existing CSAT resources.
        NAMI applauds the administration's recognition that the Federal
    Government can do a better job helping communities couple housing and
    services funding. This is a good first step. However, we are concerned
    that the chronically homeless demonstration would take $3.7 million
    from existing resources and only States with existing 1115 Medicaid
    waivers can apply. NAMI urges this subcommittee to ensure that an
    optimal number of States and public housing authorities, who administer
    Housing Choice Vouchers, can use the Medicaid and SAMHSA funding
    available for this program to more effectively target chronically
    homeless individuals living with mental illness.
        Overall, NAMI urges this subcommittee to provide $120 million in
    SAMHSA homeless programs for essential mental health and substance use
    treatment services linked to permanent supportive housing for
    chronically homeless individuals and families. This request would
    increase funding by $45 million more than the fiscal year 2010 funding
    level. NAMI also supports the President's recommendation for $15.8
    million for SAMHSA's portion of the administration's Homeless
    Initiative Program for fiscal year 2011.
    Continue Progress on Addressing the Social Security Disability Claims
            and Appeals Backlog
        Mr. Chairman, people with mental illness and other severe
    disabilities have been bearing the brunt of the backlog crisis for
    disability claims and appeals at Social Security. Behind the numbers
    are individuals with disabilities whose lives have unraveled while
    waiting for decisions--families are torn apart; homes are lost; medical
    conditions deteriorate; once stable financial security crumbles; and
    many individuals die. NAMI congratulates this subcommittee on the
    progress made since 2008 with the appropriation for SSA's Limitation on
    Administrative Expenses (LAE), boosting it to $11.447 billion for
    fiscal year 2010. This investment, along with ARRA funds to improve
    information technology has allowed SSA to hire new staff, reduce
    processing times and make progress on the reducing the disability
    claims backlog. NAMI urges the subcommittee to continue this progress
    and support the President's recommendation for an LAE of $12.521
    billion for fiscal year 2011.
    Conclusion
        Chairman Harkin, thank you for the opportunity to share NAMI's
    views on the Labor, Health and Human Services, and Education, and
    Related Agencies Subcommittee's fiscal year 2011 bill. NAMI's consumer
    and family membership thanks you for your leadership on these important
    national priorities.
                                     ______

              Prepared Statement of the National AHEC Organization

        The National AHEC Organization (NAO) is the professional
    organization representing Area Health Education Centers (AHECs). Our
    message is simple:
      --The Area Health Education Center program is effective and provides
            vital services and national infrastructure.
      --Area Health Education Centers are the workforce development,
            training and education machine for the nation's healthcare
            safety-net programs.
        AHEC is one of the Title VII Health Professions Training programs,
    originally authorized at the same time as the National Health Service
    Corps (NHSC) to create a complete mechanism to provide primary care
    providers for Community Health Centers (CHCs) and other direct
    providers of healthcare services for underserved areas and populations.
    The plan envisioned by creators of the legislation was that the CHCs
    would provide direct service. The NHSC would be the mechanism to fund
    the education of providers and supply providers for underserved areas
    through scholarship and loan repayment commitments. The AHEC program
    would be the mechanism to recruit providers into primary health
    careers, diversify the workforce, and develop a passion for service to
    the underserved in these future providers, i.e., Area Health Education
    Centers are the workforce development, training and education machine
    for the Nation's healthcare safety-net programs. The AHEC program is
    focused on improving the quality, geographic distribution and diversity
    of the primary care healthcare workforce and eliminating the
    disparities in our Nation's healthcare system.
        AHECs develop and support the community based training of health
    professions students, particularly in rural and underserved areas. They
    recruit a diverse and broad range of students into health careers, and
    provide continuing education, library and other learning resources that
    improve the quality of community-based healthcare for underserved
    populations and areas.
        The Area Health Education Center program is effective and provides
    vital services and national infrastructure. Nationwide, in 2006, AHECs
    introduced more than 308,000 students to health career opportunities,
    and more than 41,000 mostly minority and disadvantaged high school
    students received more than 20 hours each of health career programs and
    academic enhancement. AHECs support health professional training in
    more than 19,000 community based practice settings, and more than
    111,000 health professional students received training at these sites.
    Further, over 368,000 health professionals received continuing
    education through AHECs. AHECs perform these education and training
    services through collaborative partnerships with Community Health
    Centers (CHCs) and the National Health Service Corps (NHSC), in
    addition to Rural Health Clinics (RHCs), Critical Access Hospitals,
    (CAHs), Tribal clinics and Public Health Departments.
        While our partner programs, the National Health Service Corps and
    the Community Health Centers program have received much recognition of
    late and are identified as Presidential Initiatives, the AHEC program
    has been overlooked. AHEC is designed to meet the needs of the
    communities it serves, and to bridge the resources of universities,
    state and Federal programs, bringing those resources to the community.
    As a program with a national network, AHEC has a significant
    infrastructure. This infrastructure can provide the mechanism for
    information dissemination for Clinical and Translational Services to
    reduce the time it takes for bench science findings to become part of
    medical practice. AHECs can deliver minority health programs and
    already focus on recruiting minorities into health careers.
        In the past decade many new programs have been developed by Federal
    initiatives which compete with the mission of AHEC and utilize Federal
    resources to duplicate the AHEC infrastructure. Public resources would
    be better spent by utilizing the national network that AHEC represents,
    rather than reproducing the infrastructure through the creation of
    other programs.
        AHEC was recently reauthorized in the Patient Protection and
    Affordable Care Act of 2010. We were pleased to that this program was
    reauthorized for the first time since 1998, and reauthorized at $125
    million.
    Community Health Centers and the National Health Service Corps
        CHCs are dedicated to providing preventive and ambulatory
    healthcare to uninsured and underinsured populations. A March 2006
    study published in the Journal of the American Medical Association
    (JAMA) found that CHCs report high percentages of provider vacancies,
    including an insufficient supply of dentists, pharmacists,
    pediatricians, family physicians and registered nurses. These shortages
    are particularly pronounced in CHCs that serve rural areas. The study
    serves as an important reminder that the success of CHCs is highly
    dependent upon a well-trained clinical staff to provide care. Because
    title VII programs, including AHECs, have a successful record of
    training providers to work in underserved areas, the study recommends
    increased support for the Title VII Health Professions Training
    programs as the primary means of alleviating the health professions
    shortage in rural CHCs. In 2006, 46 percent of AHEC training sites were
    CHCs, and an additional 25 percent of placements were in Rural Health
    Clinics.
        The scope of collaborative activities between AHECs and CHCs is
    substantial and the populations served through these activities are
    culturally and geographically diverse.
        The interrelationships between AHECs and CHCs are numerous, and the
    added-value to the community from the unique contributions of each is
    undeniable in terms of access to quality healthcare.
        AHECs collaborate with CHCs by:
      --Assisting CHCs with the development of community boards of
            directors and often serving as board members;
      --Recruiting health professionals/staff;
      --Facilitating clinical training opportunities for health professions
            students/trainees within CHC clinic sites;
      --Conducting continuing education programs and other library and
            learning resources for health and human services professionals
            employed at CHC clinic sites.
        AHECs also undertake a variety of programs related to the placement
    and support of National Health Service Corps scholars and loan
    repayment recipients. NHSC scholars and loan repayment recipients
    commit to practicing in an underserved area, and are focused on
    improving health by providing comprehensive team-based healthcare that
    bridges geographic, financial and cultural barriers. As contractors of
    the NHSC Student/Resident Experiences and Rotations in Community Health
    (SEARCH) program, AHECs help to expand the NHSC by placing students and
    residents in rotations in rural areas. These students and residents are
    then more likely to return to rural and underserved areas as a NHSC
    scholar or loan repayment recipient since health professionals who
    spend part of their training providing care for rural and underserved
    populations are 3 to 10 times more likely to practice in rural and
    underserved areas after graduation or program completion.
        AHECs frequently place health professions students in sites that
    are approved for NHSC personnel. NHSC scholars and loan repayers serve
    as preceptors or these students. These sites give the students a view
    of working in communities with great need, seeing the potential for a
    fulfilling career, thus strengthening the connection between these
    students and service to the underserved through the NHSC.
    Justification for Recommendations
        By improving the quality, geographic diversity, and diversity of
    the healthcare workforce, the United States can eliminate healthcare
    disparities. An October 2006 study by the Health Resources and Services
    Administration (HRSA) entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' shows the importance of
    the programs like AHEC. This study found that minority health
    professionals disproportionately serve minority and other medically
    underserved populations, minority populations tend to receive better
    care from practitioners of their own race or ethnicity, and non-English
    speaking patients experience better care, greater comprehension, and
    greater likelihood of keeping follow-up appointments when they see a
    practitioner who speaks their own language.
        In order to continue the progress that the Title VII Health
    Professions Training programs, especially AHECs, have already made
    towards their goal, an additional Federal investment is required. NAO
    recommends that the AHEC program is funded at $125 million, consistent
    with its recent reauthorization amount.
                                     ______

       Prepared Statement of the National Association for Public Health
                       Statistics and Information Systems

        The National Association for Public Health Statistics and
    Information Systems (NAPHSIS) welcomes the opportunity to provide this
    written statement for the public record as the Labor, Health and Human
    Services, and Education, and Related Agencies Appropriations
    Subcommittee prepares its fiscal year 2011 appropriations legislation.
    NAPHSIS represents the 57 vital records jurisdictions that collect,
    process, and issue birth and death records in the United States and its
    territories, including the 50 States, New York City, the District of
    Columbia and the 5 territories. NAPHSIS coordinates the activities of
    the vital records jurisdictions among the jurisdictions and with
    Federal agencies by developing standards, promoting consistent
    policies, working with Federal partners, and providing technical
    assistance to the jurisdictions.
        NAPHSIS respectfully requests that the subcommittee provide the
    National Center for Health Statistics' (NCHS) National Vital Statistics
    System $11 million in fiscal year 2011--consistent with the President's
    request--to support the States and territories as they implement the
    2003 birth and death certificates and electronic data collection
    systems.
        Collection of birth and death data through vital records is a State
    function and thus governed under State laws. NCHS purchases birth and
    death data from the States to compile national data on vital events--
    births, deaths, marriages, divorces, and fetal deaths. These data are
    used to monitor disease prevalence and our nation's overall health
    status, develop programs to improve public health, and to evaluate the
    effectiveness of those interventions. For example, birth data have been
    used to:
      --Establish the relationship of smoking and adverse pregnancy
            outcomes;
      --Link the incidence of major birth defects to environmental factors;
      --Establish trends in teenage births;
      --Determine the risks of low birth weight; and
      --Measure racial disparities in pregnancy outcomes.
        Just as fundamentally, death data are used to:
      --Monitor the infant mortality rate as a leading international
            indicator of the Nation's health status;
      --Track progress and regress in reducing mortality from the leading
            causes of death, such as heart disease, cancer, stroke, and
            diabetes;
      --Document racial disparities; and
      --Otherwise provide sound information for programmatic interventions.
        Most recently, vital statistics have grabbed headlines with Amnesty
    International's report of increases in pregnancy related deaths.
        Years of chronic underfunding at NCHS have threatened the
    collection of these important data on the national level, to the extent
    that in fiscal year 2007, NCHS would have been unable to collect a full
    12 months of vital statistics data from States. Had the subcommittee
    not intervened with a small but critical budget increase to continue
    vital statistics collection, the United States would have been the
    first Nation in the industrialized world to be without a complete
    year's worth of vital data. Countless national programs and businesses
    that depend on vital events information would have been immeasurably
    affected.
        Since that time, the subcommittee has continually supported NCHS's
    vital statistics cooperative with the States. NAPHSIS and the broader
    public health community deeply appreciate these efforts. This year, we
    are pleased the President is following the subcommittee's lead in
    seeking to build a 21st century national statistical agency, requesting
    a $23 million increase for NCHS in fiscal year 2011, including $11
    million targeted for the modernization of the National Vital Statistics
    System. This increase will support states as they upgrade their
    outdated and vulnerable paper-based vital statistics systems,
    addressing critical needs for activities that have been on hold or
    curtailed because of budget constraints.
        As we make significant strides in implementing and meaningfully
    using health information technology, it is imperative that we similarly
    invest in building a modern vital statistics system that monitors our
    citizens' health, from birth until death. The requested $11 million in
    funding will move us toward a timelier and more comprehensive vital
    statistics infrastructure where all states collect the same data and
    all States collect these data electronically. Two forms of birth and
    death certificates are in use by States--the older 1989 standard
    certificate and the newer 2003 standard certificate This more recent
    birth certificate revision includes data on insurance and access to
    prenatal care, education level of parents, labor and delivery
    complications, delivery methods, congenital anomalies of the newborn,
    maternal morbidity, mother's weight and height, breast feeding status,
    maternal infections, and smoking during pregnancy, among other factors.
    The 2003 death certificate includes data on smoking-related, pregnancy-
    related, and job-related deaths.
        Currently, only 75 percent of the States and territories use the
    2003 standard birth certificate and 65 percent have adopted the 2003
    standard death certificate. Many States continue to rely on paper-based
    records, a practice which compromises the timeliness and
    interoperability of these data. Jurisdictions that had planned and
    budgeted to upgrade their certificates and systems have seen funding
    for these projects erode as States face severe budget shortfalls. These
    jurisdictions need the Federal Government's help to complete building a
    21st century vital statistics system. The President's requested down
    payment will help in this regard, allowing all jurisdictions to
    implement the 2003 birth certificate and electronic birth record
    systems. Approximately $30 million is needed to modernize the death
    statistics system; but the President's request of $3 million is
    nonetheless an important first step. However, we request that the
    subcommittee not require a State match for funds to modernize death
    certificates, as proposed by the President. NAPHSIS's members most in
    need of Federal support have indicated that a State-match requirement
    would inadvertently prevent jurisdictions from applying for these
    funds. Indeed, if States had available funds to invest in system
    improvements they would do so.
        As the historic Patient Protection and Affordable Care Act is
    implemented, the vital statistics purchased by NCHS from States are
    needed more than ever to track Americans' health and evaluate our
    progress in improving it. The President's request of $11 million for
    the National Vital Statistics System will lead to vast improvements in
    data collection and further enable us to better compare critical
    information on a local, State, regional, and national basis. Without
    additional funding, a potential erosion of State data infrastructure
    and lack of standardized data will undeniably create enormous gaps in
    critical public health information and may have severe and lasting
    consequences on our ability to appropriately assess and address
    critical health needs.
        NAPHSIS appreciates the opportunity to submit this statement for
    the record and looks forward to working with the subcommittee.
                                     ______

    Prepared Statement of the National Association of People With AIDS and
                                  VillageCare

        The National Association of People with AIDS (NAPWA) and
    VillageCare are submitting joint written comments on the appropriations
    for domestic HIV programs for Federal fiscal year 2011. Overall, NAPWA
    and VillageCare believe that the President's request for fiscal year
    2011 spending on domestic HIV programs, while including some increases
    in funding, is insufficient to meet the needs of persons living with
    HIV/AIDS in this country. We urge you to increase funding for domestic
    HIV/AIDS programs in the fiscal Labor, Health and Human Services, and
    Education, and Related Agencies; Transportation and Housing and Urban
    Development, and Related Agencies; and Financial Services and General
    Government bills for the upcoming fiscal year.
        Founded in 1983, NAPWA is the first coalition of people living with
    HIV/AIDS in the world, as well as the oldest AIDS organization in the
    United States. NAPWA is a trusted, independent voice representing the
    more than 1 million people living with HIV/AIDS in America.
        VillageCare is a community-based organization serving seniors,
    persons living with HIV and AIDS, and others who face chronic and
    disabling conditions. Founded in New York's Greenwich Village nearly 35
    years ago, the not-for-profit organization developed some of the first
    care and program responses to the AIDS epidemic in the 1980s, and has
    created a number of innovative programs and services, including the
    first AIDS day treatment program in the country and the largest AIDS
    skilled nursing facility.
        With more than 56,000 new HIV infections annually and the United
    States already having more than 1.1 million people living with HIV,
    coupled with the rising cost of medical care and other services, we
    urgently need to allocate sufficient resources to address unmet care
    and treatment needs of persons living with HIV. It is estimated that 29
    percent of persons living with HIV/AIDS in the United States are
    uninsured. The HIV epidemic also continues to have a disproportionate
    impact on communities of color and on low-income individuals.
        For nearly a decade, the HIV epidemic in the United States has
    faced serious underfunding, as the previous administration chose not to
    focus priorities on the Nation's own HIV challenges. Increases in
    funding are desperately needed to make up for these years of neglect.
        While passage of healthcare reform promises to contribute
    significantly to filling the gap in health coverage, the most critical
    provisions in the new law do not kick in until 2014. This means that
    over the next 4 years, there will be persons living with HIV who will
    have to wait for access to treatment that could save their lives.
        During this gap in time, it is vital for Congress to act to fill
    the void in resources that would connect people to care.
        We offer the following recommendations where Congress can move to
    address vital HIV care and treatment needs.
    Increase Funding in the Ryan White Program by $810.8 Million, for Total
            Funding of $3,101.5 Billion
        This includes a breakdown of funding as follows:
      --Part A.--Increase of $225.9 million for total of $905 million.
      --Part B: Care.--Increase of $55.9 million for a total of $474.7
            million.
      --Part B: AIDS Drug Assistance Program.--Increase of $370.1 million
            for a total of $1,205.1 million.
      --Part D.--Increase of $131 million for a total of $337.9 million.
      --Part F: AIDS Education Training Centers.--Increase of $15.2 million
            for a total of $50 million.
      --Part F: Dental.--Increase of $5.4 million for a total of $19
            million.
      --Part F: Special Projects of National Significance.--Support funding
            of $25 million (level funding).
        In many regions of the country, financing through Ryan White is
    often the only means to pay for healthcare and supportive services for
    many persons living with HIV/AIDS. Unfortunately, the President's
    proposed funding for the Ryan White HIV/AIDS program was increased by
    only $40 million, with many parts of the Ryan White program remaining
    flat-funded. Advocates in the HIV community have called upon the
    administration to provide at least $810 million in new resources to
    meet growing demand. The Nation needs continued aggressive action if we
    are to close the gap in access to treatment and care that exists for
    many persons living with HIV. Ryan White programs serve approximately
    577,000 low-income, uninsured, and underinsured individuals each year.
    For many people living with HIV, Ryan White-funded programs are the
    sole lifeline to HIV care, treatment and services.
    Support Emergency Supplemental Funding in Fiscal Year 2010 for the AIDS
            Drug Assistance Program (ADAP) in the Amount of $126 Million
        Eleven States have waiting lists with more than 850 people waiting
    to get access to life saving HIV medications. In addition, many States
    have greatly restricted the drugs covered by the ADAP and restricted
    eligibility so that fewer people quality for ADAP benefits. Urgent,
    immediate emergency supplemental ADAP funding that would flow to these
    programs during the current fiscal year will help address this crisis.
    Expand Access to Housing by Increasing Housing Opportunities for People
            With AIDS (HOPWA) Funding by $75 Million, for a Total of $410
            Million
        Access to safe and affordable housing is essential to improving
    individual health outcomes and promoting public health. Improved
    housing status is strongly associated with increased access and
    adherence to care and with lowered rates of HIV risk behaviors. Demand
    for AIDS housing far exceeds availability and increased HOPWA funding
    is needed to support efforts to address this critical component of the
    HIV care continuum. In the light of flat funding across many Federal
    programs, the President's proposed HOPWA increase of $5 million is far
    too small to make any meaningful impact on the rising numbers of
    persons who are without access to stable housing.
    Increase Efforts To Respond to the Disproportionate Impact of HIV Among
            Communities of Color by Increasing Funding for the Minority
            AIDS Initiative (MAI) by $207.1 Million, for Total Funding of
            $610 Million
        Targeted funding is urgently needed to address the huge disparities
    in HIV infection among communities of color. MAI funding improves
    access to culturally and linguistically appropriate outreach,
    education, prevention, care and treatment programs and services.
    Support new Investments in HIV Prevention Education by Increasing
            Funding at the Centers for Disease Control and Prevention (CDC)
            by $878 Million, for Total Funding of $1,606 Million
        A significant increase in funding of HIV prevention initiatives is
    needed to reduce the number of new HIV infections, which have remained
    unchanged at about 56,000 per year since 2001. State and local health
    departments and community-based organizations need adequate resources
    to strengthen and expand HIV testing, outreach and prevention education
    programs.
    Increase Funding for AIDS Research at the National Institutes of Health
            (NIH) by $410 Million, for Total Funding of $3.5 Billion
        A lack of sufficient funding for the NIH has slowed important
    research efforts aimed at ending the HIV/AIDS epidemic in the United
    States. To reverse this trend, funding increases are needed for the
    Office of AIDS Research at NIH.
    Support the $1.4 Million in Appropriations for National HIV/AIDS
            Strategy Implementation, Coordination, Evaluation, and
            Monitoring
        The National Strategy will be unveiled this year and this
    appropriation will be needed to achieve its goals. As National HIV/AIDS
    Strategy implementation begins, Congress must renew this $1.4 million
    appropriation, which is contained in the Financial Services and General
    Government appropriations bill. In each of fiscal year 2009 and fiscal
    year 2010, Congress appropriated $1.4 million for the White House
    Office of National AIDS Policy to help fund the cost of developing a
    comprehensive national HIV/AIDS strategy.
        VillageCare and NAPWA look forward to working with Congress and the
    administration to find more resources to address the significant unmet
    need for HIV primary medical care and supportive services that exists
    across the United States. We and others in the HIV community were
    extremely pleased with the steps taken by the Obama administration in
    the first year. The President has expressed and demonstrated leadership
    on behalf of the HIV community with such actions as the 4-year
    extension of the Ryan White Care Act and ending the HIV travel ban.
        At the same time, the Federal budget for fiscal year 2011 will need
    significant modification and additions if we are to fulfill the vision
    of the President and others to end the AIDS epidemic in the United
    States.
        Thank you.
                                     ______

    Prepared Statement of the National Assembly on School-Based Health Care
        I am grateful for this opportunity to submit written testimony on
    behalf of the National Assembly on School-Based Health Care, an
    organization representing the interests of school-based health centers
    (SBHCs). SBHCs ensure that 1.7 million children and adolescents across
    the country gain access to comprehensive medical care, mental health
    services, preventive care, social services, and youth development.
    These services are provided without concern for students' ability to
    pay in a location that meets children and adolescents where they are:
    at school.
        The Patient Protection and Affordable Care Act (Public Law111-148)
    includes a Federal authorization for SBHCs in section 4101(b)--a huge
    victory for vulnerable children and adolescents and for SBHCs.
    Secretary Sebelius agrees: ``We are thrilled that part of the [health
    reform] legislation calls for an expanded foot print of school-based
    health clinics . . . I can't think of a better way to deliver primary
    care and preventive care to not only students but their families than
    through school-based clinics.'' \1\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services Secretary Kathleen
    Sebelius, during her opening plenary remarks at the Coalition for
    Community School's national forum in Philadelphia; April 7, 2010.
    ---------------------------------------------------------------------------
        However, the School-Based Health Clinic authorization needs to be
    appropriated if SBHCs are to continue to serve our Nation's youth.
    Until funds are appropriated, only limited Federal support exists for
    SBHC operations, leaving little hope for the expansion that is called
    for by Secretary Sebelius.
        SBHCs are designed to meet the healthcare needs of students, and
    are considered one of the most effective strategies for delivering high
    quality, comprehensive, and culturally competent primary and preventive
    care to children and adolescents. At SBHCs, developmentally appropriate
    health services are provided by qualified health professionals,
    incorporating the principles and practices of pediatric and adolescent
    healthcare recommended by the American Medical Association, the
    American Academy of Pediatrics, and the American Association of Family
    Physicians. A recent study showed that SBHCs have positive impacts on
    student achievement--particularly increasing grade point averages and
    attendance.\2\
    ---------------------------------------------------------------------------
        \2\ ``Impact of School-Based Health Center Use on Academic
    Outcomes,'' Journal of Adolescent Health 46 (2010) 251-257.
    ---------------------------------------------------------------------------
        We respectfully request a $50 million appropriation to fund the
    SBHC authorization for Federal fiscal year 2011. These funds could
    provide the full operations budget of up to 200 school-based health
    centers for a year, but will likely be used to support many more. In
    the current economic climate, many State programs are struggling to
    maintain support for the SBHCs they currently fund, much less expand
    operations. We hear with increasing frequency from SBHCs about the need
    for expanded primary care hours, oral health, and expanded mental
    health services. Regrettably, some SBHCs have already had to close
    their doors, due to lack of funding for healthcare services.
        We would also like to share our concern that without support for
    the operational costs needed to support a clinic, the effectiveness of
    the capital money already allocated to SBHCs in the Affordable Care Act
    under section 4101(a) will be greatly limited. The funds allocated in
    section 4101(a), although important, are limited to capital
    improvements and equipment purchases. Expenditures for healthcare
    services and personnel are specifically excluded. The present risk and
    largest difficulty for SBHCs is the cost of care. The capital funds
    could allow some SBHCs to be built or expanded, but clinics need a
    sustainable source of operations funding in order to provide services
    for the children and adolescents who depend on them for care.
        Only a fraction (28 percent) of SBHCs can be supported in any way
    by the funds allocated in the healthcare reform legislation for
    community health centers. The majority of SBHCs are sponsored by
    entities ineligible for community health center funding, such as
    hospitals.
        The original House-passed bill identified a $50 million
    appropriation for the newly authorized school-based health center
    program. These funds will give critical resources to communities that
    desire to open health clinics at their schools and keep their existing
    clinics open.
        For the above reasons, we respectfully request that a $50 million
    appropriation be provided for the SBHC Authorization for fiscal year
    2011. Thank you for this opportunity.
                                     ______

    Prepared Statement of the National Alliance of State & 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.
        On behalf of NASTAD, we urge your support for increased funding for
    Federal HIV/AIDS and viral hepatitis programs in the fiscal year 2011
    Labor, Health and Human Services, and Education, and Related Agencies
    Subcommittee bill. We ask the subcommittee on Labor, Health and Human
    Services, and Education to demonstrate its commitment to addressing the
    domestic HIV epidemic and ramp up support for a much larger blood-borne
    epidemic, that of chronic viral hepatitis. We thank you once again for
    the increases provided to HIV/AIDS and hepatitis programs in fiscal
    year 2010 and ask for consideration of the following critical funding
    needs for HIV/AIDS, viral hepatitis and STD programs in fiscal year
    2011.
    HIV/AIDS Care and Treatment Programs
        The Health Resources and Services Administration (HRSA) administers
    the $2.2 billion Ryan White Program that providing health and support
    services to more than 500,000 HIV-positive individuals. NASTAD requests
    a minimum increase of $426 million in fiscal year 2011 for State Ryan
    White part B grants, including an increase of $56 million for the part
    B Base and $370 million for AIDS Drug Assistance Programs (ADAPs). With
    these funds 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. In 2008, it is estimated that ADAPs nationwide
    served nearly 165,000 HIV-infected individuals, nearly one-quarter of
    people with HIV/AIDS estimated to be receiving care. This is due to a
    number of factors including, increased testing efforts and
    unemployment.
        State ADAPs provide medications to low-income individuals with HIV
    disease who have limited or no coverage from private insurance or
    Medicaid. With the rise in unemployment and individuals losing their
    insurance, ADAPs are increasingly in crisis. As of April 2010, 10
    States report that 859 individuals are on a waiting list to receive
    their life-sustaining medications through ADAP:
      --Idaho.--25 individuals
      --Iowa.--62 individuals
      --Kentucky.--191 individuals
      --Montana.--17 individuals
      --North Carolina.--356 individuals
      --South Carolina.--33 individuals
      --South Dakota.--32 individuals
      --Tennessee.--55 individuals
      --Utah.--74 individuals
      --Wyoming.--14 individuals
        Sixteen States have additional cost containment measures in place
    or are anticipating implementing measures.
    ADAPs with Other Cost-containment Strategies (instituted since April 1,
            2009)
      --Arizona.--Reduced formulary
      --Arkansas.--Reduced formulary, lowered financial eligibility to 200
            percent of FPL
      --Colorado.--Reduced formulary
      --Hawaii.--Individuals with CD4>350 not currently on ARV therapy are
            not being enrolled
      --Iowa.--Reduced formulary
      --Kentucky.--Reduced formulary
      --Missouri.--Reduced formulary
      --North Carolina.--Reduced formulary
      --North Dakota.--Cap on Fuzeon
      --Utah.--Reduced formulary, lowered financial eligibility to 250
            percent of FPL
      --Washington.--Client cost sharing, reduced formulary (for uninsured
            clients only)
    ADAPs Considering New/Additional Cost-containment Measures (before
            March 31, 2011)
        Arizona.--Waiting list
        Hawaii.--Waiting list
        Illinois.--Waiting list, reduced formulary, lowered financial
    eligibility, capped enrollment, monthly expenditure cap
        Kentucky.--Reduced formulary
        Louisiana.--Capped enrollment
        North Carolina.--Lowered financial eligibility
        North Dakota.--Waiting list, reduced formulary, capped enrollment,
    annual expenditure cap
        Oregon.--Waiting list, reduced formulary
        South Dakota.--Reduced formulary
        Wyoming.--Lowered financial eligibility, annual expenditure cap
        In fiscal year 2009, 48 percent of ADAPs experienced cuts in State
    contributions to their programs and at least 35 percent of programs are
    anticipating cuts to their ADAPs in fiscal year 2010. Program
    restrictions can lead to dangerous treatment interruptions, which
    encourage drug resistance and discourage patient retention in care,
    both of which have profound effects on public health. As discretionary
    programs, ADAPs are dependent on annual Federal and State
    appropriations to serve all those in need of treatment.
        Ryan White part B Base programs include ambulatory medical
    services, case management, laboratory services, and primary care
    networks that improve the overall HIV care systems in States. Primary
    care and the provision of drug treatments are inextricably linked.
    People living with HIV need access to trained HIV clinicians and a full
    range of support services to live as healthy a life as possible to
    ensure adherence to complicated treatment regimens. Unfortunately,
    limited funding has resulted in waits of up to 6 months for a primary
    care visit.
    HIV/AIDS Prevention and Surveillance Programs
        NASTAD requests an increase of $181 million for State and local
    health department cooperative agreements in order to provide
    comprehensive prevention programs. To be successful, health departments
    must expand outreach, HIV testing, and linkage into care targeting
    high-risk populations including gay men of all races, black women,
    persons who inject drugs, and youth. 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 and HIV testing
    recommendations. In order to maximize prevention efforts, partners of
    persons being tested need to be identified, notified, and counseled. In
    addition, health departments need resources to educate the mass public
    by reinforcing accurate, evidence-based information and beginning to
    reduce the stigma associated with the disease.
        An estimated 56,300 new infections occur every year while State and
    local HIV prevention cooperative agreements have been cut by $23
    million over the last decade. NASTAD surveyed States and found that in
    fiscal year 2009, State HIV/AIDS programs were cut by $170 million.
    Seventy-four percent of States responding to NASTAD's survey reported
    cuts to HIV prevention programs. States also reported that almost 200
    HIV/AIDS staff positions have been cut or gone unfilled. These cuts
    make the Federal resources for prevention all the more critical to
    mounting an effective response to the epidemic.
        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. To be successful, 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 and HIV testing recommendations. In
    order to maximize prevention efforts, partners of persons being tested
    need to be identified, notified, and counseled. 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. In addition, health departments need resources to
    educate the mass public by reinforcing accurate, evidence-based
    information and beginning to reduce the stigma associated with the
    disease.
        NASTAD also supports the President's request of $26.9 million for a
    new initiative targeting gay men and other men who have sex with men
    (MSM). We believe this funding should come out of HIV funding and not
    STD and viral hepatitis increases as proposed.
        NASTAD requests that $48 million be allocated to health departments
    to maintain the Expanded Testing Initiative (ETI). In fiscal year 2009,
    CDC awarded $40.2 million to 20 States and 5 cities to support routine
    testing in clinical settings targeting highly impacted populations,
    particularly African Americans. In fiscal year 2010, the ETI will be
    expanded to 24 States and 6 cities funded at $47.5 million targeting
    African Americans, Latinos, gay and bisexual men of all races, and
    persons who inject drugs. NASTAD supports maintaining $48 million for
    health departments of the $65 million for the entire initiative so that
    more individuals can learn of their HIV status and be linked into care.
    NASTAD also support the President's request of $10 million for Program
    Collaboration and Service Integration (PCSI) to all health departments
    to integrate prevention services for HIV, STD, viral hepatitis, and TB
    at the client level.
    Viral Hepatitis Prevention Programs
        NASTAD requests an increase of $30.7 million for a total of $50
    million in fiscal year 2011 for the CDC's Division of Viral Hepatitis
    (DVH) to enable State and local health departments to provide basic
    core public health services for viral hepatitis. Funds are needed for
    hepatitis B and C counseling, testing, and medical referral. States
    receive on average $90,000 for adult hepatitis prevention. DVH provides
    $5 million to fund the position of an Adult Viral Hepatitis Prevention
    Coordinator in 49 States, 5 cities, and the District of Columbia. This
    is only enough for the position and not for the provision of prevention
    services. Therefore, NASTAD requests a doubling of funding to the state
    adult viral hepatitis prevention coordinators from $5 to $10 million.
        Due to lack of funding, CDC must treat hepatitis outbreaks as
    sentinel events rather than systematically addressing hepatitis B and C
    epidemics with more than 6 million Americans infected. Addressing one
    outbreak at a time is not cost-effective nor is it preventive. The
    first step to controlling infectious diseases such as hepatitis B and C
    is establishing a surveillance system to monitor disease incidence,
    prevalence, and trends. While there is no vaccine for hepatitis C,
    investing in hepatitis A and B vaccines is essential to providing
    prevention for high-risk adults and the elimination of both diseases.
    Hepatitis disproportionately impacts minorities and must be addressed
    in the context of health disparities. Approximately half of persons
    with chronic HBV are Asian Americans. Furthermore, HBV is most
    prevalent among immigrants from HBV-endemic countries (Asia and sub-
    Saharan Africa) who were infected at birth or childhood. Of the 24,000
    HBV-infected women who give birth every year, half are Asian Americans.
    HCV infection is 2 to 3 times as prevalent in African Americans as it
    is in whites.
        The recently released IOM report, Hepatitis and Liver Cancer: A
    National Strategy for Prevention and Control of Hepatitis B and C found
    that the public health response needs to be significantly ramped up.
    IOM's report attributes low public and provider awareness to the lack
    of public resources. The report makes 17 out of 22 recommendations
    specific to State health departments. In order to implement these
    recommendations to improve the Federal response, resources must be
    increased to health departments who provide the frontline response to
    these epidemics. For example, hepatitis C is the most common blood-
    borne, chronic viral disease in the United States with up to 4 million
    Americans suffering from chronic HCV infection-nearly four times the
    amount of those with HIV. Although transmission of hepatitis C has
    significantly decreased in the United States over the past 20 years,
    the incidence of liver disease and liver cancer is rising, as persons
    infected with hepatitis C decades ago begin to develop complications of
    their infection. Without increased resources for counseling, testing
    and medical referral services, the CDC predicts that deaths due to HCV
    will double by 2020.
    STD Prevention Programs
        NASTAD supports an increase of $213.5 million for a total of $367.4
    million in fiscal year 2011 for STD prevention, treatment and
    surveillance activities undertaken by state and local health
    departments. CDC's Division of STD Prevention has prioritized four
    disease prevention goals-Prevention of STD-related infertility, STD-
    related adverse pregnancy outcomes, STD-related cancers and STD-related
    HIV transmission. STD prevention programs at CDC have been cut by $6
    million since fiscal year 2004 while the number of persons infected
    continues to climb. CDC estimates that 19 million new infections occur
    each year, almost half of them among young people ages 15 to 24. In one
    year, the United States spends more than $8 billion to treat the
    symptoms and consequences of STDs. Untreated STDs contribute to infant
    mortality, infertility, and cervical cancer. Additional Federal
    resources are needed to reverse these alarming trends and reduce the
    Nation's health spending.
    Minority AIDS Initiative
        NASTAD also supports total funding of $610 million for the Minority
    AIDS Initiative (MAI) in fiscal year 2011. The MAI provides targeted
    resources to address the HIV/AIDS epidemic in hard-hit communities of
    color. MAI resources supplement the funding to states to address the
    epidemic in these communities. The data from CDC on the
    disproportionate impact on African American continues to be staggering.
    Support for the MAI along with the traditional funding streams that
    serve these populations is essential.
    Comprehensive Sex Education
        NASTAD supports the teen pregnancy prevention initiative and asks
    that it be expanded to include prevention of HIV and STDs and funded at
    the President's request of $134 million. Programs targeted to youth in
    and out of school require an inter-departmental approach through the
    collaboration of HHS agencies, including the Agency for Children and
    Families, CDC's Division of Adolescent and School Health, and the
    Office of Population Affairs. We also support an increase of $20
    million, for a total of $60.2 million, for the Division of Adolescent
    and School Health's HIV Prevention Education Program to increase access
    to evidence-based and comprehensive approach to sex education. Programs
    targeted to youth in and out of school require an inter-departmental
    approach through the collaboration of HHS agencies, including the
    Office of Adolescent Health, the Office of Population Affairs, the
    Agency of Children and Families, and CDC's Division of Adolescent and
    School Health.
        As you craft the fiscal year 2011 Labor, Health and Human Services,
    and Education 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 Association of Workforce Boards

        Thank you for the opportunity to comment on the administration's
    proposed 2011 budget for the Department of Labor. The National
    Association of Workforce Boards (NAWB) is a member association, which
    represents a majority of the 575 local employer-led Workforce
    Investment Boards and their nearly 13,000 employer member volunteers.
        We write in support of the administration's fiscal year 2011
    overall appropriations request for the Training and Employment Services
    account under the Department of Labor. Adequate funding for the public
    workforce system has never been more critical. We are in the midst of
    the worst economic downturn in our lifetimes and the public workforce
    system has been stretched to its capacity, but continues to respond
    during this time of crisis.
        Our employment crisis is not expected to ease in the foreseeable
    future. The annual Economic Report of the President released in
    February indicated that unemployment would remain above 8 percent
    through 2012. Federal Reserve Chairman Ben Bernanke was also
    pessimistic in his testimony before the Joint Economic Committee on
    April 14 regarding any large scale employment growth in the near term:

        ``As you know, the labor market was particularly hard hit by the
    recession. Recently, we have seen some encouraging signs that layoffs
    are slowing and that employment has turned up. Manufacturing employment
    increased for a third month in March, and the number of temporary
    jobs--often a precursor of more permanent employment--has been rising
    since last October. New claims for unemployment insurance continue on a
    generally downward trend. However, if the pace of recovery is moderate,
    as I expect, a significant amount of time will be required to restore
    the 8\1/2\ million jobs that were lost during the past 2 years. I am
    particularly concerned about the fact that, in March, 44 percent of the
    unemployed had been without a job for 6 months or more. Long periods
    without work erode individuals' skills and hurt future employment
    prospects. Younger workers may be particularly adversely affected if a
    weak labor market prevents them from finding a first job or from
    gaining important work experience''.

        Workforce Investment Act programs have been on the front lines of
    assisting job seekers impacted by the recession. Over the past year,
    the Workforce Investment Act (WIA) system has seen over 7.6 million
    American workers turn to it for help in navigating the labor market in
    search of jobs and/or the training individuals need to be competitive
    in their labor market. This is a 60.2 percent increase in the number of
    people served through Employment and Training Administration programs
    over the previous year. In comparison, 4.1 million workers were
    assisted during the same period the previous year.
        Despite six job seekers nationally for every available job, those
    who received WIA services were likely to find jobs, with the likelihood
    increasing the higher the service level:
        Performance Results:
      --Workforce Investment Act Adult Program:
        --Entered Employment Rate--68.1 percent
        --Employment retention rate--83.3 percent
      --Average 6 months' earnings--$14,695
      --Workforce Investment Act Dislocated Worker Program:
        --Entered employment rate--70 percent
        --Employment retention rate--85.9 percent
        --Average 6 months' earnings--$16,304
      --Workforce Investment Act Youth Program:
        --Placement in employment or education rate--66.7 percent
        --Attainment of degree or certificate rate--58.2 percent
        The ability of the pubic workforce system to maintain this level of
    success on behalf of job seekers and employers seeking skilled workers
    is incumbent upon the continuation of adequate funding. We encourage
    the subcommittee to fund WIA formula programs at a minimum at the
    administration's request levels, as we expect to continue to face the
    challenges brought about by high unemployment for the foreseeable
    future.
    Workforce Innovation Fund
        We applaud the administration's proposal for a $322 million
    Workforce Innovation Fund. We believe that the State and local
    workforce boards have developed a host of promising practices since WIA
    was enacted in 1998, particularly in helping address the large numbers
    of persons dislocated during this recession or shut-out of the labor
    market due to a lack of appropriate skills. The Workforce Innovation
    Fund will allow local areas to engage with community partners and
    quickly scale effective practices on behalf of jobseekers in need.
        However, we strongly urge the subcommittee to fully fund the
    administration's request for WIA formula programs before allocating
    funding for the Workforce Innovation Fund, as these formula funds are
    essential to our ability to provide services to job seekers at the
    local level around the Nation.
        The protection of the WIA formula programs is particularly
    important this year with the diminution of the remaining workforce
    funding in the American Recovery and Reinvestment Act, which have been
    heavily invested in providing training for job seekers. The bulk of
    these funds have been fully obligated at the local level, leaving
    little funding to commit for new trainees who seek services in the
    coming year. This funding ``cliff'' will provoke a large measure of
    frustration for individuals who are seeking services and are eligible,
    but for whom there are no funds available.
        We suspect this is a well hidden policy issue since our current
    system of financial tracking counts expenditures but lacks the capacity
    to account for monies that are obligated by contract but not invoiced
    by the provider and paid by the fiscal agent.
    Summer Youth employment
        While our testimony is focused on fiscal year 2011 funding, we
    would be remiss if we did not express our appreciation for the
    Chairman's inclusion of ARRA funding for WIA Youth programs which
    allowed 313,000 young people to have summer jobs last year who
    otherwise would not have been employed. Most of these ARRA funding for
    WIA Youth have been expended at this point, but local workforce
    programs are in the process of preparing for another expanded summer
    youth program with the limited funds they currently have available.
        We hope that any emergency spending bill enacted this work period
    will include additional funding for WIA Youth programs to allow us to
    better address the looming crisis we are facing in youth employment
    this summer.
    Policy Riders
        NAWB would strongly encourage the subcommittee to continue the
    policy riders that prohibit the redesignation of local areas or changes
    to the definition of administrative costs until WIA is reauthorized.
    There have been instances where there has been arbitrary action to
    reconfigure local areas and NAWB believes these riders will prevent any
    State v. local conflict until reauthorization.
        We urge the subcommittee to continue to provide the support
    necessary for the workforce system to help our jobseekers retool for
    employment in high demand sectors and maintain our global
    competitiveness.
        Thank you for the opportunity to testify.
                                     ______

                  Prepared Statement of the Nursing Community

        The Nursing Community is a forum for professional nursing and
    related organizations to collaborate on a wide spectrum of healthcare
    and nursing issues including practice, education, and research. These
    53 organizations are committed to promoting America's health through
    nursing care. Collectively, the Nursing Community represents more than
    850,000 Registered Nurses (RNs), Advanced Practice Registered Nurses
    (APRNs), nurse executives, nursing students, nursing faculty, and nurse
    researchers. Together, our organizations work collaboratively to
    increase funding for the Nursing Workforce Development programs,
    authorized under title VIII of the Public Health Service Act (42 U.S.C.
    296 et seq.) so that American nurses have the support needed to provide
    high-quality care to their patients.
    The National Nursing Shortage Continues to Impact Quality Care
        Since 1998, the United States has experienced a significant
    shortage of RNs, which has dramatically impacted the quality of care
    provided by our Nation's healthcare delivery system. In March 2007, a
    comprehensive report initiated by the Federal Agency for Healthcare
    Research and Quality was released on Nursing Staffing and Quality of
    Patient Care. The authors found that the shortage of RNs, in
    combination with an increased workload, poses a potential threat to the
    quality of nursing care. In settings with inadequate nurse staffing,
    patient safety was compromised. However, increases in RN staffing were
    associated with reductions in hospital-related mortality and failure to
    rescue, as well as reduced lengths of stay. A robust supply of well-
    educated nurses is essential to ensure that all Americans receive
    quality healthcare and that our Nation has the nurses necessary to meet
    the current and future demands.
        The demand for nurses will continue to grow as the baby-boomer
    population ages, nurses retire, and the need for healthcare
    intensifies. According to the U.S. Bureau of Labor Statistics (BLS),
    nursing is the Nation's top profession in terms of projected job growth
    with more than 581,000 new nursing positions being created through 2018
    (a 22 percent increase in the workforce). Further, BLS analysts project
    that more than 1 million new and replacement nurses will be needed by
    2016.
        Currently, RNs comprise the largest group of health professionals
    with approximately 3.1 million providers offering essential care to
    patients in a variety of settings, including hospitals, long-term care
    facilities, community or public health areas, schools, workplaces, and
    home care. In addition, many nurses receive graduate degrees that allow
    them to practice autonomously as APRNs; become nurse faculty, nurse
    researchers, nurse administrators, and public health nurses; and work
    in the policy area to help shape healthcare delivery. With the new
    health reform law focused on creating a system that will increase
    access to quality care, emphasize prevention, and decrease cost, it is
    critical that a substantial investment be made in our healthcare
    workforce, particularly an investment in nurses. RNs and APRNs are
    vital to ensuring direct availability to high-quality, cost-effective
    healthcare in a reformed system. Nurses are involved in every aspect of
    healthcare, and if the nursing workforce is not strengthened, the
    healthcare system will continue to suffer.
    Reversing the Nursing Shortage: A Federal Solution
        Throughout previous nursing shortages, particularly in the 1960s
    and 1970s, the Federal Government has offered relief to nursing schools
    and students to reverse the negative trend. In particular, the Nursing
    Workforce Development programs offered viable solutions to nursing
    shortages, expanded nursing school programs, increased the number of
    nurse faculty, and helped ensure nurses were practicing in areas with a
    critical shortage. As Congress searches for programs to address the
    nursing shortage now and in the future, the title VIII programs have
    been and continue to be a proven solution.
    Nursing Workforce Development Programs
        The Nursing Workforce Development programs have supported the
    supply and distribution of qualified nurses to meet our Nation's
    healthcare needs since 1964. Over the last 46 years, these programs
    have addressed all aspects of nursing shortages--education, practice,
    retention, and recruitment. The title VIII programs bolster nursing
    education at all levels, from entry-level preparation through graduate
    study, and provide support for institutions that educate nurses for
    practice in rural and medically underserved communities. Between fiscal
    year 2006 and 2008, the title VIII programs supported 214,575 nurses
    and nursing students as well as numerous academic nursing institutions,
    and healthcare facilities. Today, the title VIII programs are essential
    to solving the current national nursing shortage.
    Title VIII Effectiveness
        Results from the American Association of Colleges of Nursing's
    (AACN) 2009-2010 Title VIII Student Recipient Survey included responses
    from 1,420 students who noted that these programs played a critical
    role in funding their nursing education. The survey showed that three-
    quarters of the students receiving title VIII funding are attending
    school full-time. By supporting full-time students, the title VIII
    programs are helping to ensure that students enter the workforce
    without delay. The programs also address the current demand for primary
    care providers. A high percentage of the students surveyed (49.1
    percent) reported that their career goal is to become a nurse
    practitioner. Approximately 80 percent of nurse practitioners provide
    primary care services throughout the United States. Additionally, the
    nurse faculty shortage continues to inhibit the ability of nursing
    schools to increase student capacity and address the shortage. Of the
    students who responded to the survey, 40.5 percent stated their
    ultimate career goal was to become nurse faculty.
    Nursing Students Supported by Title VIII Funding
        Of the title VIII student recipients surveyed, 39 percent reported
    that they received between $1,001-$3,000 in funding over 1 year. Sixty-
    seven percent reported that this funding supported a portion of their
    tuition, and 35.8 percent reported that the funding was dedicated to
    books and educational materials. Fifty-two percent of the students
    responded that the title VIII funding paid for 25 percent or less of
    their total student loans. Of those students, 26 percent stated that
    the funding paid for less than 5 percent of their total nursing student
    loans. When asked how the title VIII programs could be improved, the
    overwhelming response from students was to increase the funding in
    order to provide higher levels of support for their education.
        Nursing students rely upon support through title VIII to complete
    their degree and offset their considerable educational expenses.
    Continued and increased support for the title VIII programs can help
    address the demand for nursing services.
        The Nursing Community respectfully request $267.3 million (a 10
    percent increase) for the Nursing Workforce Development programs
    authorized under title VIII of the Public Health Service Act in fiscal
    year 2011. Last year, your subcommittee provided a significant funding
    boost for title VIII that helped support the Loan Repayment program and
    Scholarship and Nurse Faculty Loan program. These increases will
    bolster the pipeline of nurses and nurse faculty, which is so critical
    to reversing the nursing shortage. We feel it is extremely important to
    maintain last year's funding level for these critical programs in
    fiscal year 2011 and direct the 10 percent requested increase for the
    four title VIII program that have not kept pace with inflation since
    fiscal year 2005. The Advanced Education Nursing, Nursing Workforce
    Diversity, Nurse Education, Practice, and Retention, and Comprehensive
    Geriatric Education programs expand nursing school capacity and
    increase patient access to care. These programs would greatly benefit
    from the 10 percent increase awarded in proportion to their fiscal year
    2010 funding level. Below is a description of these four critical
    programs.
        Advanced Education Nursing (AEN) Grants (section 811) support the
    preparation of RNs in master's and doctoral nursing programs. The AEN
    grants help to prepare our Nation's nurse practitioners, clinical nurse
    specialists, nurse midwives, nurse anesthetists, nurse educators, nurse
    administrators, public health nurses, and other nurse specialists
    requiring advanced education. In fiscal year 2008 (most current data
    available), these grants supported the education of 5,649 students.
      --AEN Traineeships assist graduate nursing students by providing full
            or partial reimbursement for the costs of tuition, books,
            program fees, and reasonable living expenses. In fiscal year
            2008, this funding helped support 6,675 graduate nurses and
            APRNs.
      --Nurse Anesthetist Traineeships (NAT) support the education of
            students in nurse anesthetist programs. In some States,
            Certified Registered Nurse Anesthetists (CRNAs) are the sole
            anesthesia providers in almost 100 percent of rural hospitals.
            Much like the AEN Traineeships, the NAT provides full or
            partial support for the costs of tuition, books, program fees,
            and reasonable living expenses. In fiscal year 2008, the
            program supported 2,145 future CRNAs.
        Workforce Diversity Grants (section 821) prepare disadvantaged
    students to become nurses. This program awards grants and contract
    opportunities to schools of nursing, nurse managed health centers,
    academic health centers, State or local governments, and nonprofit
    entities looking to increase access to nursing education for
    disadvantaged students, including racial and ethnic minorities under-
    represented among RNs. In fiscal year 2008, the program supported
    11,638 students.
        Nurse Education, Practice, and Retention Grants (section 831) help
    schools of nursing, academic health centers, nurse-managed health
    centers, State and local governments, and healthcare facilities
    strengthen programs that provide nursing education. In fiscal year
    2008, the priority areas under this program supported 42,761 with an
    additional 455 students supported by the Integrated Nurse Education
    Technology program.
        Comprehensive Geriatric Education Grants (section 855) are awarded
    to schools of nursing or healthcare facilities to better provide
    nursing services for the elderly. These grants are used to educate RNs
    who will provide direct care to older Americans, develop and
    disseminate geriatric curriculum, prepare faculty members, and provide
    continuing education. In fiscal year 2008, this program supported 6,514
    nurses and nursing students.
        Without an adequate supply of nurses to care for our Nation,
    including our growing aging population, the healthcare system is not
    sustainable. The Nursing Community's request of $267.3 million in
    fiscal year 2011 for the HRSA Nursing Workforce Development programs
    will help ensure access to quality care provided by America's nursing
    workforce.
    Members of the Nursing Community Submitting this Testimony
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Academy of Nurse Practitioners
    American Academy of Nursing
    American Association of Colleges of Nursing
    American Association of Nurse Anesthetists
    American College of Nurse Practitioners
    American College of Nurse-Midwives
    American Nurses Association
    American Organization of Nurse Executives
    American Psychiatric Nurses Association
    American Society for Pain Management Nursing
    Association of Community Health Nursing Educators
    Association of Nurses in AIDS Care
    Association of periOperative Registered Nurses
    Association of Rehabilitation Nurses
    Association of Women's Health, Obstetric and Neonatal Nurses
    Commissioned Officers Association of the U.S. Public Health Service
    Dermatology Nurses' Association
    Gerontological Advanced Practice Nurses Association
    Hospice and Palliative Nurses Association
    Infusion Nurses Society
    National Association of Clinical Nurse Specialists
    National Association of Hispanic Nurses
    National Association of Nurse Practitioners in Women's Health
    National Association of Pediatric Nurse Practitioners
    National Black Nurses Association
    National Nursing Centers Consortium
    National Organization of Nurse Practitioner Faculties
    National Student Nurses' Association, Inc.
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Preventive Cardiovascular Nurses Association
    Public Health Nursing Section, American
    Public Health Association
    Society of Urologic Nurses and Associates
    Wound, Ostomy and Continence Nurses Society
                                     ______

    Prepared Statement of the National Council for Diversity in the Health
                                  Professions

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to present my views before you today. I am Dr. Wanda
    Lipscomb, President of the National Council for Diversity in the Health
    Professions (NCDHP) and the Director of the Center of Excellence for
    Culture Diversity in Medical Education at Michigan State University.
    NCDHP, established in 2006, is a consortium of our Nation's majority
    and minority institutions that once house the Health Resources and
    Services (HRSA) Minority Centers of Excellence (COE) and Health Careers
    Opportunities Programs (HCOP) when there was more funding. These
    institutions are committed to diversity in the health professions. In
    my professional life, I have seen firsthand the importance of health
    professions institutions promoting diversity and the Title VII Health
    Professions Training programs.
        Mr. Chairman, time and time again, you have encouraged your
    colleagues and the rest of us to take a look at our Nation and evaluate
    our needs over the next 10 years. I want to say that minority health
    professional institutions and the Title VII Health Professionals
    Training programs address a critical national need. Persistent and
    severe staffing shortages exist in a number of the health professions,
    and chronic shortages exist for all of the health professions in our
    Nation's most medically underserved communities. Furthermore, our
    Nation's health professions workforce does not accurately reflect the
    racial composition of our population. For example while blacks
    represent approximately 15 percent of the U.S. population, only 2-3
    percent of the Nation's health professions workforce is black. Mr.
    Chairman, I would like to share with you how your committee can help
    NCDHP continue our efforts to help provide quality health professionals
    and close our Nation's health disparity gap.
        There is a well-established link between health disparities and a
    lack of access to competent healthcare in medically underserved areas.
    As a result, it is imperative that the Federal Government continue its
    commitment to minority health profession institutions and minority
    health professional training programs to continue to produce healthcare
    professionals committed to addressing this unmet need.
        An October 2006 study by the Health Resources and Services
    Administration (HRSA), entitled ``The Rationale for Diversity in the
    Health Professions: A Review of the Evidence'' found that minority
    health professionals serve minority and other medically underserved
    populations at higher rates than nonminority professionals. The report
    also showed that; minority populations tend to receive better care from
    practitioners who represent their own race or ethnicity, and non-
    English speaking patients experience better care, greater
    comprehension, and greater likelihood of keeping follow-up appointments
    when they see a practitioner who speaks their language. Studies have
    also demonstrated that when minorities are trained in minority health
    profession institutions, they are significantly more likely to: (1)
    serve in rural and urban medically underserved areas; (2) provide care
    for minorities; and (3) treat low-income patients.
        As you are aware, Title VII Health Professions Training programs
    are focused on improving the quality, geographic distribution and
    diversity of the healthcare workforce in order to continue eliminating
    disparities in our Nation's healthcare system. These programs provide
    training for students to practice in underserved areas, cultivate
    interactions with faculty role models who serve in underserved areas,
    and provide placement and recruitment services to encourage students to
    work in these areas. Health professionals who spend part of their
    training providing care for the underserved are up to 10 times more
    likely to practice in underserved areas after graduation or program
    completion.
        Institutions that cultivate minority health professionals, like the
    NCDHP members, have been particularly hard-hit as a result of the cuts
    to the Title VII Health Profession Training programs in fiscal year
    2006, fiscal year 2007, and fiscal year 2008. Given their historic
    mission to provide academic opportunities for minority and financially
    disadvantaged students, and healthcare to minority and financially
    disadvantaged patients, minority health professions institutions
    operate on narrow margins. The cuts to the Title VII Health Professions
    Training programs amount to a loss of core funding at these
    institutions and have been financially devastating. We have been
    pleased to see efforts to revitalize both COE and HCOP in recent fiscal
    years, but it is important to fully fund the programs at least at the
    fiscal year 2004 level so that more diversity is achieved in our health
    professions.
        Earlier this year with the passage of health reform, the Congress
    showed the importance of the many of the title VII programs, including
    the COE and HCOP, by reauthorizing the programs.
        COE.--COEs focus on improving student recruitment and performance,
    improving curricula in cultural competence, facilitating research on
    minority health issues and training students to provide health services
    to minority individuals. COEs were first established in recognition of
    the contribution made by four historically black health professions
    institutions (the Medical and Dental Institutions at Meharry Medical
    College; The College of Pharmacy at Xavier University; and the School
    of Veterinary Medicine at Tuskegee University) to the training of
    minorities in the health professions. Congress later went on to
    authorize the establishment of ``Hispanic'', ``Native American'' and
    ``Other'' Historically black COEs. For fiscal year 2011, I recommend a
    funding level of $33.6 million for COEs.
        HCOP.--HCOPs provide grants for minority and nonminority health
    profession institutions to support pipeline, preparatory and recruiting
    activities that encourage minority and economically disadvantaged
    students to pursue careers in the health professions. Many HCOPs
    partner with colleges, high schools, and even elementary schools in
    order to identify and nurture promising students who demonstrate that
    they have the talent and potential to become a health professional.
        Collectively, the absence of HCOPs will substantially erode the
    number of minority students who enter the health professions. Over the
    last three decades, HCOPs have trained approximately 30,000 health
    professionals including 20,000 doctors, 5,000 dentists and 3,000 public
    health workers. For fiscal year 2011, I recommend a funding level of
    $35.6 million for HCOPs.
        Mr. Chairman, please allow me to express my appreciation to you and
    the members of this subcommittee. With your continued help and support,
    NCDHP member institutions and the Title VII Health Professions Training
    programs can help this country to overcome health and healthcare
    disparities. Congress must be careful not to eliminate, paralyze or
    stifle the institutions and programs that have been proven to work.
    NCDHP seeks to close the ever widening health disparity gap. If this
    subcommittee will give us the tools, we will continue to work towards
    the goal of eliminating that disparity everyday.
        Thank you, Mr. Chairman, and I welcome every opportunity to answer
    questions for your records.
                                     ______

    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, in this testimony, NFCB:
      --Thanks the subcommittee for its role in providing $25 million
            station fiscal stabilization in light of the difficult economy
            in last year's appropriation;
      --Requests $604 million in funding for CPB for fiscal year 2013 and
            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
            the radio ``minority consortia'' dedicated to Native American,
            Latino and African-American radio stations;
      --Requests $59.5 million in fiscal year 2011 for conversion of public
            radio and television to digital technology;
      --Supports CPB's funding for rural stations and assistance with new
            technologies and requests report language regarding rural and
            minority stations in this regard
      --Supports CPB programs focused on ensuring public radio is able to
            fulfill its important mission of public safety during
            emergencies; and
      --Supports CPB's role as a convener that can address questions and
            important future trends across all public media.
        Community radio fully supports the forward funding appropriation of
    $604 million in Federal funding for the Corporation for Public
    Broadcasting in fiscal year 2013. Money allocated to the Corporation
    for Public Broadcasting assists NFCB member stations throughout the
    country through community service grants. Community service grants are
    the core way that CPB uses to support radio stations--particularly
    targeted to stations offering the first public radio service to a
    community in a rural area, or to stations serving particular
    demographic constituencies. CPB's focus on these areas is critical to
    ensuring that public radio does not focus solely on higher-income
    audiences, but serves every American no matter their background or
    their location. These targeted 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. CPB 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 importantly,
    the insulation that advance funding provides is of critical importance
    in eliminating both the risk of and the appearance of undue
    interference with and control of public broadcasting.
        Community radio supports CPB activities in facilitating programming
    to Native American, Latino, and African-American radio stations. CPB
    has played a critical role in providing support and assistance to radio
    stations serving communities of color, particularly communities that
    could be better served by noncommercial radio. While CPB has long
    supported television programming focused on underserved communities,
    its programs for radio are newer and are very welcome. Given the
    importance and accessibility of radio in many underserved communities,
    NFCB urges the subcommittee to endorse the long-term viability of these
    radio minority consortia.
        Specifically, with important support from CPB, Native Public Media
    (NPM) has burst on to the scene to ensure that Native Americans have
    access to noncommercial broadcast and new technologies alike. NPM has
    worked in the last few years to facilitate applications for
    noncommercial radio stations by almost 40 applicants from tribal and
    native entities, bringing many of these service areas within the reach
    of a public radio signal for the first time. NPM has undertaken
    research to identify the spectrum allocations currently serving Indian
    Country in order to target better service in the future, releasing a
    report called The New Media, Technology and Internet Use in Indian
    Country: Quantitative and Qualitative Analyses, which included a usage
    survey and case study that contains the first valid and credible data
    on Internet use among Native Americans. In addition, NPM was able to
    play a critical role in ensuring that tribal entities have the ability
    to obtain new radio stations in the future by successfully
    demonstrating to the FCC the need and legal justification for a tribal
    priority in radio.
        In addition, in the last year the newest minority consortium has
    been started--the Latino Public Radio Consortium. The Latino Public
    Radio Consortium is an organization that represents and supports 33
    public radio stations. It recognizes that Latinos are underrepresented
    in the Nation's public broadcasting institutions, decisionmaking
    structures, that there is little programming in English or in Spanish
    produced by Latinos or with a Latino focus and, as a consequence,
    Hispanics are vastly underrepresented among public radio's news and
    public affairs audiences.\1\ To illustrate, a study by Station Resource
    Group's Grow the Audience project showed that, for public radio to
    acquire a representative share of the college-educated market for
    Latinos, it would need to triple its audience.\2\
    ---------------------------------------------------------------------------
        \1\ Latino Public Radio Consortium, Brown Paper, p. 1 available at
    http://www.latinopublicradioconsortium.org/index.php?s=41.
        \2\ Station Resource Group, Grow the Audience, Listening by Black
    and Hispanic College Graduates (2008) at p. 17, available at http://
    www.srg.org/GTA/GTA%20Black%20Hispanic%20Report.pdf.
    ---------------------------------------------------------------------------
        During this funding year the Consortium has established the
    communications and governance structure to enable the Hispanic stations
    to support each other and to develop additional resources. An important
    new project that is indicative of future work is the development of
    Historias, a partnership with Story Corps, a national oral history
    project of the Library of Congress and public radio. Through this
    collaboration, Story Corps Historias will gather and record 900
    individual interviews with Latinos around the country.
        This year CPB is funding new services for African American public
    radio stations designed to improve and increase public media's service
    to the American public. NFCB believes that this project, like the other
    consortia, is vital to ensure that all Americans benefit from public
    funds and the breadth and depth of public radio. In addition to the
    minority consortia, CPB supports Satelite Radio Bilinge which 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. CPB also supports Native Voice One (NV1), which
    is distributing politically and culturally relevant programming to
    Native American stations.
        Community radio supports $59.5 million in fiscal year 2011 for the
    conversion to digital technology. While public television's digital
    conversion needs were 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.
    This development of second and third audio channels will potentially
    double or triple the service that public radio can provide listeners,
    particularly in unserved and underserved communities. In addition,
    public radio is in great need of CPB's leadership and resources to
    transition to new media platforms, in particular through such projects
    as the American Archive, which will make existing programming
    accessible to all and on all platforms.
        Community radio supports CPB's funding for rural stations and
    assistance with new technologies. 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 so that 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.
        A good example of CPB's role is the Public Media Innovation grant
    CPB gave KAXE, one of NFCB's rural members, a chance to experiment with
    the concept of becoming ``a web operation that owned a radio station.''
    PMI described this project as one of the most visionary proposals they
    funded. As part of the grant, KAXE began the development of Northern
    Community Internet, which would provide hyper-local news content to
    more than a dozen communities in northern Minnesota. Through this
    project, KAXE learned many important things about how to create content
    that is relevant and accessible across a web site, radio station, and
    social media. The journalists involved continue to be very interested
    in the project, even though the current pilot is over.
        Community radio supports CPB programs focused on ensuring public
    radio is able to fulfill its important mission of public safety during
    emergencies. CPB funding has supported an important new project led by
    NFCB called Station Action for Emergency Readiness (SAFER). NFCB, in
    partnership with NPR and with support from CPB, has developed a step-
    by-step manual that stations can use to develop and/or supplement their
    own emergency readiness plans; a set of digital tools that stations can
    embed in their own websites to keep community members informed; and
    links to national and local resources that can supplement station's
    coverage. This project was inspired by the experience of NFCB member
    WWOZ in New Orleans as a result of Katrina and was furthered by the
    work of NFCB member KWMR in Point Reyes Station, California. KWMR is
    small and local community and provided absolutely critical life-saving
    information to its community during terrible floods of 2004-2005.
        Community radio supports CPB's role as a convener that can address
    questions and important future trends across all public media. CPB
    plays an extremely important role in the public and Community Radio
    system: it convenes 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.
        Thank you for your consideration of our testimony. If the
    subcommittee has any questions or wishes to follow up on any of the
    points expressed above, please contact:
                                     ______

           Prepared Statement of the National Coalition for Literacy

        Mr. Chairman and members of the subcommittee, thank you for the
    opportunity to submit the views of the National Coalition for Literacy
    on appropriations for adult education and family literacy, under the
    Workforce Investment Act, title II.
        The National Coalition for Literacy represents 24 national
    organizations concerned about adult education and family literacy. We
    request a significant increase in funding and investment for adult
    education and family literacy to at least $750 million in order to
    address critical, immediate needs, such as:
      --Clear Waiting Lists.--It would cost at least $160 million to clear
            existing waiting lists for instruction.
      --Increase Access to Adult English Language Learning Programs.--We
            need to create opportunities for more than 11 million
            immigrants to learn English.
      --Increase Access to Professional Development.--Adult education
            practitioners need increased access to professional development
            in order to ensure quality services.
      --Improve Professional Quality of the Adult Education Workforce.--
            Eighty percent of teachers are part time; thousands are
            volunteers. We must create the conditions needed to attract and
            retain a full-time workforce.
      --Create a National Center for Adult Education, Literacy, and
            Workforce Skills.\1\ A Center would address the continued need
            for research and innovation in our field.
    ---------------------------------------------------------------------------
        \1\ NCL Proposal for a National Center for Adult Education,
    Literacy, and Workforce Skills http://www.ncladvocacy.org/
    NationalCenterPolicyPrinciples_FINAL.pdf.
    ---------------------------------------------------------------------------
        These critical, urgent needs require scaled investments that will
    provide adults important opportunities to acquire the skills they need
    to find family sustaining work.
    Need and Demand for Adult Education
        The 2003 National Assessment of Adult Literacy found that there are
    approximately 93 million adults in the United States who do not have
    the literacy skills to reach their full potential. Thirty million
    adults have such low levels of literacy that it impedes their ability
    to fully function at home, at work, and in society. One in seven adults
    in our Nation can barely read a newspaper, a job application, a
    prescription label, or an election ballot.\2\ Many live in poverty,
    experience complex health problems, and have extreme difficulty
    supporting their children's education. Eleven million adults cannot
    communicate in English.
    ---------------------------------------------------------------------------
        \2\ ProLiteracy www.proliteracy.org.
    ---------------------------------------------------------------------------
        Taking into consideration all Federal, State, and local and
    philanthropic funding, the adult education system serves only 2.5
    million of 93 million adults each year who would benefit from literacy
    and English language instruction. Despite this, adult education has
    been nearly flat funded for a decade. An increase in fiscal year 2009-
    10 was a one-time adjustment to correct for a funding calculation error
    that occurred from 2003-2008.
        According to this year's congressional justification, the
    administration built its budget request on 2006 waiting list data.\3\
    However, the National Council of State Directors of Adult Education has
    since published a March 2010 report, demonstrating that waiting lists
    and wait time have doubled in the last 2 years, during this economic
    crisis. Seventy-two percent of the programs reporting, from 50 of the
    51 States and territories, confirmed waiting lists. Approximately
    160,000 adults want to access services but cannot.\4\ Additionally,
    community-based and volunteer literacy programs around the country
    report increased demand for services while traditional sources of
    funding are becoming more scarce.
    ---------------------------------------------------------------------------
        \3\ Congressional Justification for Career, Technical, and Adult
    Education 2010 http://www2.ed.gov/about/overview/budget/budget11/
    justifications/n-careered.pdf.
        \4\ 2009-2010 Adult Student Waiting List Survey http://
    www.ncladvocacy.org/2010AdultEducationWaitingListReport.pdf.
    ---------------------------------------------------------------------------
        The congressional justification also cited 2000 census data
    demonstrating an 11 percent dropout rate nationwide. Adult education
    programs serve as a key pipeline for these dropouts, keeping them on
    course to a high school equivalent and postsecondary education or job
    training. Adult education provides a last resort for helping these
    youths get back on track.
    Investing in Adult Education is a Workforce Investment
        We commend the administration for proposing to invest more through
    the Workforce Innovation Fund. Adult education and job training can
    underpin economic recovery and open opportunities for low-skilled
    workers by helping today's workforce develop the skills they need for
    both work and community life. As literacy and educational attainment
    rise, so do adults' income and chances of stable employment.
        According to the Bureau of Labor Statistics, unemployment decreases
    as education levels increase: \5\
    ---------------------------------------------------------------------------
        \5\ Education Pays, Bureau of Labor Statistics http://www.bls.gov/
    emp/ep_chart_001.htm.

    ------------------------------------------------------------------------
                                                               Median weekly
         Unemployment rate in 2008       Education attained     earnings in
               (percentage)                                   2008 (dollars)
    ------------------------------------------------------------------------
    2.................................  Doctoral degree.....          $1,561
    1.7...............................  Professional degree.           1,531
    2.4...............................  Master's degree.....           1,233
    2.8...............................  Bachelor's degree...           1,012
    3.7...............................  Associate degree....             757
    5.1...............................  Some college, no                 699
                                         degree.
    5.7...............................  High-school graduate             618
    9.................................  Less than a high                 453
                                         school diploma.
    ------------------------------------------------------------------------
    Note: Data are 2008 annual averages for persons age 25 and over.
      Earnings are for full-time wage and salary workers.

    Source: Bureau of Labor Statistics, Current Population Survey.

        The Bureau of Labor Statistics estimates that by 2013, 90 percent
    of the fastest-growing jobs, 60 percent of all new jobs, and 40 percent
    of manufacturing jobs will require some form of postsecondary
    education. However, only 2 percent of this need can be met by high
    school graduates.\6\ 94 percent of today's workforce will still be in
    the workforce in 2013; we must increase the skills of the current adult
    workforce for these high-demand jobs. Adult education is an important
    re-entry point for unemployed and underemployed adults who wish to
    raise their basic education skills or improve their English. However,
    the adults who want to become job and career-ready for these high-
    skilled, high-demand jobs are unable to get into instruction.\7\
    ---------------------------------------------------------------------------
        \6\ U.S. Census, www.census.gov.
        \7\ Investing in the Adult Workforce http://www.ncladvocacy.org/
    StateAlignmentInitiativesVolumeII/InvestingInTheAdultWorkforce.doc.
    ---------------------------------------------------------------------------
    Meeting the President's College Graduation Goal
        The President has articulated a goal of the United States having
    the highest proportion of college graduates in the world by 2020. Even
    if every State reached the same levels of high school graduation and
    college enrollment for high school graduates as the highest-performing
    States, we would not reach this goal without a substantial effort to
    bring adult education students into the pipeline.
    English Language Acquisition
        We must create opportunities for immigrants to learn English and
    civics by building and enhancing the capacity of current adult
    education programs. Between 1970 and 2005, the U.S. foreign-born
    population tripled to an estimated 35.8 million individuals, accounting
    for 12.4 percent of the country's population. At least 67 percent of
    the growth in the U.S. workforce in the past 3 years is comprised of
    new immigrants. It is estimated that between 2010-2030 first and second
    generation immigrants together will account for all the growth in the
    U.S. workforce.\8\ According to U.S. Census Bureau estimates, nearly 1
    in 5 adults in the United States speaks a language other than English
    at home, and more than 17 million speak English less than ``very
    well.'' \9\
    ---------------------------------------------------------------------------
        \8\ Kirsch, I., Braun, H., Yamamoto, K. (2007) America's Perfect
    Storm: Three Forces Changing Our Nation's Future. Princeton, NJ:
    Education Testing Service.
        \9\ U.S. Census Bureau (2003). Language Use and English-Speaking
    Ability: 2000. Washington, DC: Author.
    ---------------------------------------------------------------------------
    Investing in Quality
        Increasing funds to clear waiting lists is a start. But if the
    adult education system is to help prepare adults for 21st century jobs,
    transition adults to college, and meet or exceed performance goals, we
    must invest in quality of the profession as well as the numbers of
    learners served. The 21st century adult educator needs to:
      --Prepare adults to be digital age learners using existing and new
            technologies.
      --Prepare adults with the basic adult literacy and critical thinking
            skills they need to be competitive in the 21st century
            workforce.
      --Teach adults with learning and other disabilities to close the life
            outcomes gap.
      --Prepare adults to transition into postsecondary and vocational
            credit-bearing classes.
      --Instruct a linguistically diverse classroom to improve their
            language proficiency.
      --Increase political literacy and civic participation among our
            nation's adults.
      --Strengthen programs to be scalable and flexible to meet new demands
            in communities.
        Only 1 in 5 adult education teachers are full time; thousands are
    volunteers; most are funded on year-to-year grant programs. Stable job
    status that facilitates a dedicated, professional workforce is critical
    to raising student achievement outcomes. Career ladders are virtually
    nonexistent in adult education; a national credential in adult
    education does not exist. Many practitioners are not paid to attend
    professional development opportunities in order to meet these demands
    upon them. Developing the professional quality of the workforce is
    vital if we are to help adult learners achieve. We must increase access
    to professional development, provide credentialing and career
    advancement opportunities, improve working conditions, and conduct
    research in professional development. Increasing appropriations will
    allow the field to do that.
    Return on Investment
        Adult education is a good investment. On January 21, 2010, the
    United States Department of Labor's Bureau of Labor Statistics reported
    that there was a $9,828 wage differential for full-time workers with a
    high school diploma (or GED) over those who did not graduate.\10\ The
    following is the potential return on investment for adults in 2008-2009
    who received a GED in adult education programs. Over a 5-year period,
    the original $39,164,868 spent on the 165,637 GED students shows a
    potential return on investment of $1,220,910,325 (3,017 percent).
    ---------------------------------------------------------------------------
        \10\ Bureau of Labor Statistics (January 2010). Retrieved February
    16, 2010 from http://www.bls.gov/news.release/wkyeng.nr0.htm.

    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Number of GEDs achieved in 2008-2009.................       \1\ $165,637
    Average dollars invested in student..................            $236.45
                                                          ------------------
          Total..........................................        $39,164,868

    Number of GEDs achieved in 2008-2009.................            165,637
    Income differential..................................             $9,828
                                                          ------------------
          Total increase in taxable income per year......     $1,627,880,436

    Federal tax rate (percent)...........................                 15
                                                          ------------------
          Potential return on investment per year........       $244,182,065
    One-year return on investment (percent)..............                523
                                                          ------------------
          Potential 5-year return on investment..........     $1,220,910,325
    ------------------------------------------------------------------------
    \1\ Office of Vocational and Adult Education reporting Web site.
      Retrieved February 16, 2010.

        The current levels of funding have not and will not allow the field
    to grow to serve more adults, to improve and innovate practice, and
    meet existing and increasing demands. For these reasons, we strongly
    urge the Senate Appropriations Subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies to support a significant
    increase for programs provided by the Adult Education and Family
    Literacy Act, to at least $750 million or more.
                                     ______

             Prepared Statement of the National Consumer Law Center

        The Federal Low Income Home Energy Assistance Program (LIHEAP) \1\
    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. The demand for LIHEAP assistance remains at record high
    levels. In fiscal year 2010, the program is expected to help a record 9
    million low-income households afford their energy bills, a 15 percent
    increase from the prior fiscal year. 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 2011 and that advance
    funding of $5.1 billion be provided for the program in fiscal year
    2012.
    ---------------------------------------------------------------------------
        \1\ 42 U.S.C. Sec. Sec. 8621 et seq.
    ---------------------------------------------------------------------------
    Home Energy Bills Remain High at a Time When Unemployment and
            Underemployment is at Record High Levels
        Residential heating expenditures remain at high levels. U.S.
    average residential heating expenditures this winter are expected to be
    around the same for natural gas, about 24 percent higher for heating
    oil, 21 percent higher for propane, and 23 percent higher for
    electricity when compared to the 5-year average for 2003-2008.\2\ The
    years of steady, high-energy bills are hitting low-income households
    struggling in this serious economic downturn. Low-income residential
    consumers, on average, pay a substantial amount of their income on
    residential energy, especially when compared to non-low-income
    households, 13.5 percent versus 3.6 percent, respectively.\3\ Because
    LIHEAP is targeted to the most vulnerable low-income households, LIHEAP
    recipient households have an average energy burden of 16 percent.\4\
    ---------------------------------------------------------------------------
        \2\ Derived from data in the Energy Information Agency, Short-Term
    Energy Outlook (March 2010), Table WF01.
        \3\ US HHS, ACF, OCS, LIHEAP Home Energy Notebook For Fiscal Year
    2007, June 2009 at Table A-3b. Residential energy: Average annual
    expenditure, by amount (dollars) and mean individual burden (percent of
    income), for all, non-low-income, low income, and LIHEAP recipient
    households, by Census region and main heating fuel, fiscal year 2007.
        \4\ Id.
    ---------------------------------------------------------------------------
        The number of households that are struggling to make ends meet
    remains very high. According a Pew Economic Policy Group report, in
    March 2010 more than 44 percent of the 15 million unemployed Americans
    had been unemployed for 6 months or longer.\5\ This is the highest rate
    of long-term unemployment since World War II. The ``underemployment''
    rate in March 2010 is 16.9 percent.\6\ CBO's budget and economic
    outlook report projects that unemployment will average 9.5 percent in
    fiscal year 2011.\7\ The hardship low-income households face is also
    apparent in the data below on the number of households falling behind.
    ---------------------------------------------------------------------------
        \5\ Pew Economic Policy Group Fiscal Analysis Initiative, A Year or
    More: The High Cost of Long-Term Unemployment, April 2010, Executive
    Summary.
        \6\ Id. Underemployment captures workers who became discouraged and
    stopped looking for work, older workers who opted to retire early
    instead of seeking work, young people delaying entering the work force
    and those workers who want full-time work, but have been forced to
    accept part-time work instead.
        \7\ CBO, The Budget and Economic Outlook: Fiscal Years 2010 to
    2020, January 2010 at Summary Table 2.
    ---------------------------------------------------------------------------
    States' Data On Electric and Natural Gas Disconnections and Arrearages
            Show That More Households Are Falling Behind
        States are Predicting Record LIHEAP Participation.--With the
    downturn in the economy, the States continue to experience record
    demand for LIHEAP assistance. NEADA reports that for fiscal year 2010,
    17 States have projected increases in participation of at least 20
    percent, with Mississippi estimating a 68 increase, followed by
    Washington (42 percent), Michigan (38 percent), Nevada (34 percent),
    New Jersey (31 percent), West Virginia (28 percent), Colorado (26
    percent), Kansas (25 percent), New Hampshire (25 percent), Wisconsin
    (25 percent), Montana (21 percent), California (20 percent), Oregon (20
    percent), South Carolina (20 percent), South Dakota (20 percent), Texas
    (20 percent) and Rhode Island (20 percent).\8\ As jobs lag behind
    economic recovery, we fully expect the need for fully funded LIHEAP
    program in the States in fiscal year 2011.
    ---------------------------------------------------------------------------
        \8\ NEADA press release, Record Numbers of Households Seek
    Assistance: States Call for the Release of Emergency Funds and
    Supplemental Assistance, February 22, 2010. (Hereinafter, ``NEADA Feb.
    22, 2010 Press Release.'')
    ---------------------------------------------------------------------------
        The steady and dramatic rise in residential energy costs has
    resulted in increases in electric and natural gas arrearages and
    disconnections. The National Energy Assistance Directors' Association
    reports that households experiencing natural gas shut offs increased
    from 4.1 million in 2008 to 4.3 million in 2009.\9\
    ---------------------------------------------------------------------------
        \9\ NEADA press release, Record Number of Households Receive Energy
    Assistance: Shut-Offs Exceed 4.3 million Households in 2009, December
    18, 2009. See also 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). This national survey 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 May 2008.
    ---------------------------------------------------------------------------
        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 disconnection peaks 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.
        California.--California has experienced a dramatic increase in
    LIHEAP participation from fiscal year 2008 to fiscal year 2010, with
    166,000 households served in fiscal year 2008; 434,000 in fiscal year
    2009 and projects serving 521,000 in fiscal year 2010.\10\ The rise in
    the State's unemployment and foreclosure rates led the State Division
    of Ratepayer Advocates (DRA) to take a look at whether households are
    able to maintain access to natural gas and electric service. DRA found
    that low-income residential customers were experiencing a 19 percent
    increase in disconnections over the past year and that the disparity
    between low-income disconnections and non-low-income disconnections is
    the worst in 3 years.\11\ In February 2010, the California Public
    Utilities Commission opened a docket to address electric and natural
    gas disconnections.\12\
    ---------------------------------------------------------------------------
        \10\ NEADA Feb. 22, 2010 Press Release.
        \11\ California Division of Ratepayer Advocates, Status of Energy
    Utility Service Disconnections in California, November 2009, Executive
    Summary and pages 5 and 10.
        \12\ CPUC, Order Instituting Rulemaking To Establish Ways to
    Improve Customer Notification and Education to Decrease the Number of
    Gas and Electric Utility Service Disconnections, R.10-02-005, Issued
    February 5, 2010.
    ---------------------------------------------------------------------------
        Iowa.--Iowa has experienced a steady increase in enrollment for the
    regular LIHEAP program from fiscal year 2008 to fiscal year 2010 with
    85,000 households served in fiscal year 2008; 95,000 in fiscal year
    2009 and 100,000 projected in fiscal year 2010.\13\ The average monthly
    number of LIHEAP households in arrears in fiscal year 2009 was 12
    percent higher than the monthly average over the 5-year period from
    fiscal year 2004 through fiscal year 2008. However, as a testament to
    the importance of LIHEAP, the average monthly number of all households
    in arrears in fiscal year 2009 was 14 percent higher than the monthly
    average for all households in arrears over the previous 5-year
    period.\14\
    ---------------------------------------------------------------------------
        \13\ NEADA Feb. 22, 2010 Press Release and Iowa Bureau of Energy
    Assistance.
        \14\ 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 6 percent from January 2009 to
    January 2010.\15\ The increase is an even more dramatic 98 percent
    between January 2003 and January 2010. The total dollar amount owed
    (arrearage) by low-income PIPP customers increased 5 percent from
    January 2009 to January 2010 and 118 percent when comparing PIPP
    customer arrears from January 2003 to January 2010. Ohio has
    experienced a steady increase in enrollment for the regular LIHEAP
    program from fiscal year 2008 to fiscal year 2010 with 387,000
    households served in fiscal year 2008; 394,000 in fiscal year 2009 and
    projects 418,000 in fiscal year 2010.\16\
    ---------------------------------------------------------------------------
        \15\ Public Utilities Commission of Ohio.
        \16\ NEADA Feb. 22, 2010 Press Release.
    ---------------------------------------------------------------------------
        Pennsylvania.--Pennsylvania has also experienced a steady increase
    in enrollment for the regular LIHEAP program from fiscal year 2008 to
    fiscal year 2010, with 371,000 households served in 2008; 547,000 in
    fiscal year 2009, and a projected 602,000 in fiscal year 2010.\17\
    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 21,029 households entered the current
    heating season without heat-related utility service. This number
    includes about 3,992 households who are heating with potentially unsafe
    heating sources such as kerosene or electric space heaters and kitchen
    ovens. In mid-December 2009, an additional 14,332 residences where
    electric service was previously terminated were vacant and more than
    7,438 residences where natural gas service was terminated were vacant.
    In 2009, the number of terminations increased 65 percent compared with
    terminations in 2004. As of December 2009, 18.2 percent of residential
    electric customers and 15.8 percent of natural gas customers were
    overdue on their energy bills.\18\
    ---------------------------------------------------------------------------
        \17\ Id.
        \18\ Pennsylvania Public Utilities Commission.
    ---------------------------------------------------------------------------
    LIHEAP Is a Critical Safety Net Program for the Elderly, the Disabled
            and Households With Young Children
        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.\19\ 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.\20\ 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.\21\ Clearly, families are going without food during the winter to
    pay their heating bills, and their children fail to thrive and grow. A
    2007 Colorado study found that the second leading cause of homelessness
    for families with children is the inability to pay for home energy.\22\
    ---------------------------------------------------------------------------
        \19\ 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.
        \20\ 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.
        \21\ 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).
        \22\ 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, ovens and
    burners, all of which are fire hazards. Space heaters pose 3 to 4 times
    more risk for fire and 18 to 25 times more risk for death than central
    heating. In 2007, space heaters accounted for 17 percent of home fires
    and 20 percent of home fire deaths.\23\ 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 persons 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.\24\ The CDC
    also notes that air-conditioning is the number one protective factor
    against heat-related illness and death.\25\ 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.
    ---------------------------------------------------------------------------
        \23\ John R. Hall, Jr., Home Fires Involving Heating Equipment
    (Jan. 2010) at ix and 33. Also, 40 percent of home space heater fires
    involve devices coded as stoves.
        \24\ CDC, ``Heat-Related Deaths--United States, 1999-2003'' MMWR
    Weekly, July 28, 2006.
        \25\ 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 2011 in light of high
    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
    2012 advance funding would facilitate the efficient administration of
    the State LIHEAP programs. Advance funding provides 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 for Osteoporosis and
                             Related Bone Diseases

        Mr. Chairman and members of the subcommittee: Thank you for the
    opportunity to submit testimony to this subcommittee. The National
    Coalition for Osteoporosis and Related Bone Diseases (``Bone
    Coalition'') was organized in the early 1990s and is dedicated to
    increasing Federal research funding for bone diseases through advocacy
    and education. The Bone Coalition members are five leading national
    bone disease groups, consisting of two professional societies and three
    national voluntary health organizations: American Academy of
    Orthopaedic Surgeons; American Society for Bone and Mineral Research;
    National Osteoporosis Foundation; Osteogenesis Imperfecta Foundation;
    and The Paget Foundation.
        Bone diseases do not discriminate. Osteoporosis and related bone
    diseases affect people of all ages, ethnicities, and gender. Related
    bone diseases include Paget's disease of bone, osteogenesis imperfecta,
    and a number of rare bone diseases. Osteoporosis is a condition in
    which the bones become weak and can break from a minor fall, or in
    serious cases, from a simple action such as a sneeze. About 10 million
    Americans already have the disease, and another 34 million people have
    low bone density, which puts them at risk for osteoporosis and bone
    fractures. Approximately 80 percent of those affected by osteoporosis
    are women.
        Bone diseases drastically affect the way people function.
    Individuals who suffer broken bones as a result of osteoporosis can
    suffer severe pain, loss of height, and stooped posture that can affect
    breathing and digestion. One in five patients who walked before their
    hip fracture needs long-term care afterward. It is interesting to note
    that although the rate of hip fractures is 2 to 3 times higher in
    women, after 1 year, the death rate in men is nearly twice as high.
    Studies conclude that musculoskeletal disorders and diseases are the
    leading cause of disability in the United States. Studies further
    indicate that more than 1 in 4 Americans have a musculoskeletal
    condition requiring medical attention. The annual direct and indirect
    costs for bone and joint health are $849 billion--which is 7.7 percent
    of the U.S. gross domestic product. Bone health is critical to the
    overall health and quality of life for Americans, and greater efforts
    are needed from Congress, States, providers, and patients to address
    the burdens associated with osteoporosis and related bone diseases.
    Information regarding the impact of bone diseases is included at the
    end of this statement.
    National Institutes of Health (NIH) Funding
        The Bone Coalition is grateful for the additional funding the
    President has included in his budget for the NIH. His agenda recognizes
    the role that medical research plays in building better healthcare and
    economic revitalization. We join the hundreds of organizations
    dedicated to health and medical research to now urge Congress to
    provide additional funds--$35 billion--for the NIH. This increase will
    create substantial opportunities for scientific and health advances as
    well as provide a key economic role in communities across the Nation.
    In addition, even with NIH's budget increase proposed by the President,
    not all NIH Institutes and programs will receive proportional
    increases. The Bone Coalition encourages the subcommittee to provide a
    proportional increase in funding to the National Institute of Arthritis
    and Musculoskeletal and Skin Diseases. The Coalition would like to draw
    attention to areas of bone disease research which merit funding.
        An internal analysis of fiscal year 2009 NIH funded grants revealed
    only 1 percent of the NIH budget was allotted toward bone research.
    This statistic is startling when one considers the number of
    individuals afflicted with bone diseases. Bones provide mobility,
    support, and protection for the body. The previous statistics mentioned
    in this testimony describe a compelling reason to support bone disease
    research. Furthermore, without additional bone disease research, the
    costs associated with treating bone diseases will continue to burden
    our healthcare system.
        The Coalition has identified several areas where supplemental
    research is needed and urges the NIH Institutes and other agencies to
    give priority consideration to the below research topics.
        Office of the Director.--The Coalition urges NIH to make support
    research that leads to targeted therapies to improve the density,
    quality, and strength of bone for all Americans. We also encourage
    investments in mechanisms that foster increased interdisciplinary
    research between bone and muscle, fat, and the central nervous system,
    as well as research that improves the identification of populations who
    might require earlier treatment because they are at risk of rapid bone
    loss due to obesity, diabetes, chronic renal failure and low glomerular
    filtration rates, cancer, HIV, conditions that affect absorption of
    nutrients or medications, and addiction to tobacco, alcohol or other
    opiates.
        Furthermore, the Coalition urges NIH to support research on the
    effects of bone therapies on the skeleton, including factors
    predisposing individuals to osteonecrosis of the jaw and atypical
    subtrochanteric fractures of the femur. Regarding cancer and bone,
    studies need to be expanded on prevention and repair of bone defects
    caused by cancer cells and the biology of tumor dormancy and
    therapeutic resistance. Further studies are needed to determine optimal
    levels of calcium and Vitamin D to achieve optimal bone health as well
    as the relationship between Vitamin D and morbidity and mortality in
    chronic kidney disease. Other research needs include: knowledge to
    advance the ability to diagnose and treat bone diseases and disorders
    through bone imaging; advancing tissue engineering strategies to
    replace and regenerate bone and soft tissue; developing assessments for
    determining fracture risk; and better defining the causes of age-
    related bone loss and fractures, reduced physical performance and
    frailty.
        Finally, the Coalition encourages NIH to expand genetics and other
    research on rare bone diseases, including: osteogenesis imperfecta,
    Paget's disease of bone, fibrous dysplasia, osteopetrosis, fibrous
    ossificans progressiva, melhoreostosis, X-linked hypophosphatemic
    rickets, multiple hereditary exostoses, multiple osteochondroma,
    Gorham's disease, and lymphangiomatosis.
        National Institute of Arthritis and Musculoskeletal and Skin
    (NIAMS).--The Coalition suggests additional research is needed into the
    pathophysiology of bone loss in diverse populations in order to develop
    targeted therapies to reduce fractures and improve bone density, bone
    quality, and bone strength. This includes resolving what are
    appropriate levels of calcium and vitamin D for bone health at
    different life stages. Research is also needed in the assessment of
    bone microarchitecture and remodeling rates for determining fracture
    risk, anabolic approaches to increase bone mass, novel molecular and
    cell-based therapies for bone and cartilage regeneration, and
    discerning the clinical utility of new, noninvasive bone imaging
    techniques to measure bone architecture and fragility. Support for
    studies on the molecular basis of bone diseases such as Paget's
    disease, osteogenesis imperfecta and other rare bone diseases should
    also be a priority.
        National Cancer Institute (NCI).--The Coalition requests continued
    research on how to repair bone defects caused by cancer cells,
    mechanisms by which cancer cells affect the bone's endogenous cells,
    and the biology of tumor dormancy and the role of tumor stroma in
    conferring therapeutic resistance. Additionally, research is needed to
    discern the impact of metastasis on the biomechanical properties of
    bone, how inadequate levels of vitamin D affect bone as a result of
    hard and soft tissue sarcoma, and the mechanisms by which bone marrow
    derived cells and tumor associated macrophages can influence metastatic
    growth, survival and therapeutic resistance.
        National Institute on Aging (NIA).--The Coalition encourages
    research to better define the causes of age-related bone loss and
    fractures, reduced physical performance and frailty, including
    identifying epigenetic changes, with the aim of translating basic and
    animal studies into novel therapeutic approaches. Critical research is
    also needed on changes in bone structure and strength with aging,
    periosteal biology, identifying cell autonomous changes versus
    alterations in the bone microenvironment and the relationship of age-
    related changes in other organ systems and their affects/interactions
    with bone. The prevention and treatment of other metabolic bone
    diseases, including osteogenesis imperfecta, glucocorticoid-induced
    osteoporosis, and bone loss due to kidney disease should also be
    priority research areas.
        National Institute of Child Health and Human Development (NICHD).--
    The Coalition urges research in the new, emerging field of metabolic
    disease and bone in children and adolescents, especially childhood
    obesity, anorexia nervosa and other eating disorders. Research is also
    needed on what the optimal Vitamin D levels should be in children to
    achieve maximal bone health, and the implications of chronic or
    seasonal Vitamin D deficiency to the growing skeleton. Development and
    testing of therapies and bone building drugs for pediatric patients are
    also a pressing clinical need.
        National Institute of Dental and Craniofacial Research (NIDCR).--
    The Coalition urges continued research support on the effects of
    systemic bone active therapeutics on the craniofacial skeleton,
    including factors predisposing individuals to osteonecrosis of the jaw,
    as well as novel approaches to facilitate bone regeneration.
        National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK).--The Coalition supports research on the relationship between
    Vitamin D and morbidity and mortality in chronic kidney disease.
    Research is also needed on the value of anti-resorptive therapies, the
    link between renal insufficiency and diabetic bone disease, the
    differences in calcification of blood vessels, the mechanisms of
    metastasis of renal cell carcinoma, and diseases that occurs in
    patients with end stage chronic renal disease on hemodialysis.
        National Institute of Neurological Disorders and Stroke (NINDS).--
    The Coalition encourages research support into the pathophysiology of
    spinal cord, brachial plexus, and peripheral nerve injuries in order to
    develop targeted therapies to improve neural regeneration and
    functional recovery.
        National Institute of Biomedical Imaging and Bioengineering
    (NIBIB).--The Coalition encourages critical research to advance our
    ability to treat bone diseases and disorders through bone imaging, as
    well as managing the loss of bone and soft tissue associated trauma by
    advancing tissue engineering strategies to replace and regenerate bone
    and soft tissue.
        Mr. Chairman and members of the subcommittee, the Bone Coalition
    appreciates the subcommittee's work over the years, especially your
    recognition of the need to fund research addressing disease prevention
    and treatment. With your assistance, NIH could provide the Federal
    support to ensure that bone research and bone health are priorities.
        Thank you for the opportunity to submit testimony to the
    subcommittee.
                                     ______

         Prepared Statement of the National Coalition of STD Directors

        The National Coalition of STD Directors is a nonprofit, nonpartisan
    association of public health sexually transmitted (STD) program
    directors in the 65 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 Centers for Disease Control and Prevention (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 3 to 5
    fold 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. Men who have sex with men (MSM) have
    historically experienced high rates of all STDs, including HIV/AIDS. In
    2008, 63 percent of all primary and secondary syphilis cases were among
    MSM. The syphilis rate among males is now five 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/Alaskan Natives, and Hispanics are also at higher risk
    of contracting STDs. In 2008, the rate of Chlamydia among African
    Americans was 9 times that of whites, for American Indian/Alaskan
    Natives it was 5 times higher than whites, and for Hispanics it was 3
    times higher than whites. African American women experience syphilis
    rates 15 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 declined more
    than 22 percent since fiscal year 2003, when adjusted for inflation to
    2009 U.S. dollars. 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.
        The National Coalition of STD Directors requests an fiscal year
    2011 funding level of $367.4 million, an increase of $213.5 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 (+$33 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,
    dramatic 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 (+$25 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 (PS) 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 H1N1 outbreak.
    The versatile expertise of DIS make them indispensable during a public
    health crisis, but also highlight 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. Between 1999 and 2009, STD
    programs across the nation have experienced a 20 percent reduction in
    DIS staff.
    Expand Chlamydia Screening and Infertility Prevention (+$61.5 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 HHS, 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 (USPSTF),
    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 (+$40 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 20 times greater than that of
    whites in 2008. African American men aged 15 to 19 years old experience
    gonorrhea rates 40 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 2007, 14.6 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 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 (+$44 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 114
    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 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
    men who have sex with men (MSM) and minority populations, and expanded
    screening in correctional facilities.
    Build a Response to Viral STDs (Herpes, HPV, Hepatitis B) (+$10
            million)
        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.
        The National Coalition of STD Directors also supports the
    President's fiscal year 2011 funding request of $133.7 million for the
    Teen Pregnancy Prevention Initiative, within the Office of Adolescent
    Health (OAH).
        We need to invest in programs that provide all of our young people
    with complete, accurate, and age-appropriate sex education that helps
    them reduce their risk of HIV, other STDs, and unintended pregnancy. In
    these tight budget times, we are pleased that the President's fiscal
    year 2011 budget increased funding for the new teen pregnancy
    prevention initiative. However, by focusing the funding on teen
    pregnancy prevention, and not including the equally important health
    issues of STDs and HIV, we think the administration has missed an
    opportunity to provide true, comprehensive sex education that promotes
    healthy behaviors and relationships for all young people, including
    LGBT youth. So many negative health outcomes are inter-related and we
    need to strategically and systemically provide youth with the
    information and services they need to make responsible decisions about
    their sexual health. We request that the teen pregnancy prevention
    initiative be broadened to address HIV and other STDs, in addition to
    the prevention of unintended teen pregnancy. We are pleased that the
    President's budget has once again included zero funding for failed
    abstinence-only-until-marriage programs and we encourage the
    subcommittee not to include funding for these ineffective programs.
        We urge the subcommittee to substantially increase resources to
    protect our Nation from the devastating consequences of STDs. The CDC
    has developed programs that have significantly reduced STD rates and
    the associated costs to society. We know how to prevent, control, and
    treat sexually transmitted diseases; however, without additional funds,
    the CDC cannot establish these programs to scale in all 50 States, U.S.
    territories, and directly funded cities.
                                     ______

    Prepared Statement of the National Council of State Directors of Adult
                                   Education

        Mr. Chairman, thank you for the opportunity to submit testimony
    regarding the need for additional appropriations for adult education
    programs.
        Adult education programs serve a large number of our Nation's at-
    risk citizens, from those who are unemployed to immigrants who lack the
    literacy skills needed to succeed in their new home country.
        At the present time our country is heavily investing in efforts to
    put Americans back to work. For many of our Nation's unemployed, their
    jobs have disappeared, only to be replaced by new jobs with
    requirements they cannot meet because they have low literacy skills and
    lack a high school diploma.
        To meet the needs of these individuals, adult education programs
    across the Nation are partnering with programs under title I of the
    Workforce Investment Act to develop career pathways that integrate
    adult education and occupational training programs. In addition, there
    are programs focused on transitioning participants from adult education
    programs to postsecondary education.
        But current funding levels, coupled with funding from the State and
    local level, prevent us from serving more than 2.3 million individuals
    a year. A 2010 survey demonstrates that there are waiting lists in
    every State. According to the National Assessment of Adult Literacy,
    there are approximately 93 million individuals who lack the literacy
    skills to reach their full potential. Thirty million individuals are at
    the lowest level of literacy and cannot perform basic tasks such as
    reading a bus schedule.
        With the wide gap between the number of Americans who are in need
    of improved literacy/education skills and the number that can be served
    by the current system, we strongly encourage you to increase funding
    for adult education programs to $750 million which would enable us to
    at least erase the waiting list.
        Mr. Chairman, adult education programs help put Americans back to
    work, provide new immigrants with English language skills, assist in
    transitioning individuals to higher education, and provide parents with
    the skills they need to help their children succeed in school.
        Adult education programs provide a wide range of services to many
    individuals but are currently limited in the number of individuals we
    can serve because of limited funding. While we understand the budget is
    tight, we believe increased funding for adult education will provide a
    strong return on your investment in our programs while we serve
    undereducated adults.
        Thank you again for the opportunity to submit testimony regarding
    funding for adult education programs.
                                     ______

            Prepared Statement of the National Down Syndrome Society

        Mr. Chairman and members of the subcommittee: As Vice President 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 2011.
        There are more than 400,000 people living with Down syndrome in the
    United Statement, 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 other genetic
    disorders, 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 for them and
    others with chromosomal disorders. On behalf of the National Down
    Syndrome Society, we recommend that you appropriate $5 million in the
    fiscal year 2011 to the Centers for Disease Control & Prevention (CDC)
    to implement the requirements of the Prenatally and Postnatally
    Diagnosed Conditions Awareness Act of 2007.
        As you know, Congress passed the Prenatally and Postnatally
    Diagnosed Conditions Awareness Act of 2007 in October of 2008. 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, websites, 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 and the need to communicate complex information to the
    more than 4 million women who are now offered prenatal screening and
    testing and must weigh this information in order to give informed
    consent for these new procedures.
        As recently reported in an article entitled ``Changing Practice of
    Obstetricians'', published in the American Journal of Obstetrics and
    Gynecology in April 2009, only 36 percent of obstetricians feel ``well
    qualified to counsel patients who screen positive'' for Down syndrome.
    About half (51 percent) thought the training they received during
    residency regarding screening and diagnosis for Down syndrome was
    adequate, whereas 40 percent thought it was less than adequate and 9
    percent thought it was comprehensive. Only ``29 percent of physicians
    provide the pregnant woman with printed educational materials'' if the
    fetus is diagnosed with Down syndrome.
        In another study also published in the American Journal of
    Obstetrics and Gynecology, the largest and most comprehensive study on
    prenatally diagnosed Down syndrome to date, recommendations made by
    mothers included: screening results should be clearly explained as a
    risk assessment, not as a ``positive'' or ``negative'' result;
    physicians should discuss all reasons for prenatal diagnosis including
    reassurance, advance awareness before delivery of the diagnosis of Down
    syndrome, adoption, as well as pregnancy termination; up-to-date
    information on Down syndrome should be available; results from
    amniocentesis or CVS, chorionic villi sampling, should, whenever
    possible, be delivered in person, with both parents present; sensitive
    language should be used when delivering a diagnosis of Down syndrome;
    if obstetricians rely on genetic counselors or other specialists to
    explain Down syndrome, sensitive, accurate, and consistent messages
    must be conveyed; contact with local Down syndrome support groups
    should be offered, if desired. A 29-member Down Syndrome Diagnosis
    Study Group published an article in the American Journal of Medical
    Genetics in 2009 which added to the previously mentioned
    recommendations. This study recommended that the conversation where in
    the diagnosis was delivered should provide answers to the questions:
    What is Down Syndrome? What causes the condition? What healthcare
    conditions go along with the condition? What are realistic expectations
    for a child with Down syndrome living today? Also the study recommends
    that healthcare professionals should use non-directive language and the
    healthcare professionals should arrange for a follow-up appointment
    with the parents, including any desired meetings with subspecialists.
        By including $5 million in the fiscal year 2011 Labor, Health &
    Human Services, 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 National Eczema Association

        Dear Chairman Harkin: Chairman Harkin and Members of the Senate
    Appropriations Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies, I am Julie Block, Chief Executive
    Officer of the National Eczema Association (NEA).
        As member of the Senate who strongly value the role of the National
    Institutes of Health (NIH), I am writing first to express to you my
    deep gratitude for your past support. The NIH is our Nation's
    preeminent medical research institution and represents our best hope
    for finding cures, improving treatments, and gaining a better
    understanding of the diseases and conditions that affect millions of
    Americans. On behalf of the NEA, I respectfully request your continued
    support for NIH funding.
        I would also like to thank you for inviting us to submit testimony
    on our own behalf. The NEA is a 501(c)(3) nonprofit organization that
    receives no Federal grants or sub grants, nor do we receive Federal
    contracts or subcontracts. Our mission is to help improve the health
    and quality of life of persons living with eczema/atopic dermatitis,
    including those who have the disease and their loved ones. This is a
    family disease. Through programs focused on advocacy, education, and
    research, we involve both public and private sectors in addressing
    these needs. In these current times, there is much the public does not
    know or understand about how devastating this disease can be.
        There are many types of eczemas, with atopic dermatitis (AD)
    recognized as the most severe and chronic. Atopic dermatitis is a
    genetic skin disease that affects over 30 million people in the United
    States; 10 percent of the American populations have some form of atopic
    dermatitis.
        Atopic dermatitis falls into a category of disease called atopy,
    which includes asthma and hay fever. The three together are known as
    the ``Atopic Triad.'' Atopic dermatitis almost always begins in
    childhood, usually during infancy. However, it is important to remember
    that atopic dermatitis is not just a childhood disease, as is commonly
    believed. For most people afflicted with the disease it becomes a
    lifelong sentence. The skin becomes dry, scaly, red and intensely
    itchy. It cracks, bleeds, weeps, and often gets infected.
        For many patients with eczema, one of the worst consequences of the
    disease is the isolation and withdrawal from other people and
    community. Patients are often treated as if they were lepers even
    though atopic dermatitis is not contagious. Some patients choose not to
    have children, fearful of passing on a life of suffering to yet another
    generation. Some patients feel this choice so strongly they submit to
    voluntary sterilization in young adulthood. Atopic dermatitis is an
    extremely isolating disease, regardless of whether that isolation stems
    from internal or external factors, and many severe atopics do not leave
    their homes.
        Others, like the young heroine of the story I'm about to relate,
    somehow find within themselves the courage to keep going, to keep
    fighting, to keep believing there is a place for them in the larger
    community. I hope her story not only inspires you, but inspires you to
    action.
        This is Angeline's story. Angeline is an adult atopic, having
    eczema since birth. Her nickname in school was ``Spot''--she would hide
    in the bathrooms during recess and lunchtime and scratch. She would try
    with all her might not to scratch during class, not to flake skin over
    her desk, not to crack and bleed. Constant, intolerable, itching has
    led to lifelong use of steroid treatments, both orally and topically,
    to assuage the itching and ``treat'' the eczema wounds. The constant
    itching, skin flaking off in sheets, dead, dry skin, and oozing
    abhorrent looking skin are just part of everyday life for Angeline.
        Her eczema has resulted in severe infections, and this physical
    trauma is accompanied by a level of psychic trauma few of us ever have
    to confront. She has had too many days when she can literally not get
    out of bed--the skin gets so bad that it eventually becomes a huge task
    to even move her legs and arm joints. On top of all that, her skin
    looks absolutely gruesome.
        Angeline has shed many tears, and at times wondered how she would
    go on. The years of bandaged hands to stop the scratching, steroid
    withdrawal, bank accounts spent on creams and miracle cures, vitamins
    and doctors appointments. When will it end? Some days Angeline is not
    at all available to ``face the world''.
        And people will tell you eczema is just a rash!
        As Angeline's story suggests, doctors, researchers, and scientists
    consistently underestimate the emotional consequences of this disease,
    its treatments, and its complications. The general public understands
    it even less. Before we can offer alternatives that will truly improve
    the quality of life for eczema sufferers, we must understand the
    disease mechanism and how it works. Committed physicians and ongoing
    research gives us all hope.
        The NEA is dedicated to raising awareness of these issues. The
    Association publishes a quarterly newsletter called The Advocate,
    oversees a volunteer Support Network program, distributes educational
    materials to patients and medical professionals, and conducts an annual
    Patient and Family Conference. As vocal advocates for atopic patients
    and their families, our staff attends several professional meetings
    each year, and educates governmental officials at local, State and
    national levels to provide input to the budget, research, and policy
    decisions about atopic dermatitis/eczema patients. In past years, the
    NEA educated public officials during the Government's smallpox
    vaccination campaign regarding the life-and-death consequences to
    atopic patients. We have been on Capitol Hill for NIAMS day many years
    in a row as a member of the National Institutes of Arthritis and
    Musculoskeletal and Skin Diseases Coalition to educate legislators on
    our disease.
        The NEA can boast many exciting accomplishments, including over
    $400,000 spent on eczema research since the inception of its research
    program in 2004. One of the NEA-funded grants to Dr. Gil Yosipovitch,
    MD of Wake Forest University has resulted in a major NIH grant to
    continue his work on itch. We anticipate yet another NIH award for NEA-
    funded research to continue exciting work on prevention of atopic
    dermatitis in high-risk infants.
        The NIH and the research it supports are critical to the
    advancement of improved atopic dermatitis/eczema treatment and eventual
    cure. As part of the Coalition of Skin Disease, we believe that when a
    cure is found for any of these skin diseases, there is a good chance it
    will improve our ability to find a cure for other diseases. The recent
    boost in NIH funding in 2009 and 2010 was a very important step toward
    regaining the lost potential of the last several years.
        As you work to finalize the fiscal year 2011 appropriations, on
    behalf of the NEA, I respectfully request a funding increase of at
    least 7 percent for the National Institutes of Health (NIH) compared to
    the fiscal year 2010 baseline level.
        Help us give eczema patients and their families hope for the
    pleasure of everyday life, and being good in the skin their in!
        And again, thank you for your past support of biomedical research
    funding.
                                     ______

    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, in this testimony, NFCB:
      --Thanks the subcommittee for its role in providing $25 million
            station fiscal stabilization in light of the difficult economy
            in last year's appropriation;
      --Requests $604 million in funding for CPB for fiscal year 2013 and
            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
            the radio ``minority consortia'' dedicated to Native American,
            Latino, and African-American radio stations;
      --Requests $59.5 million in fiscal year 2011 for conversion of public
            radio and television to digital technology;
      --Supports CPB's funding for rural stations and assistance with new
            technologies and requests report language regarding rural and
            minority stations in this regard
      --Supports CPB programs focused on ensuring public radio is able to
            fulfill its important mission of public safety during
            emergencies; and
      --Supports CPB's role as a convener that can address questions and
            important future trends across all public media.
        Community radio fully supports the forward funding appropriation of
    $604 million in Federal funding for CPB in fiscal year 2013. Money
    allocated to the Corporation for Public Broadcasting assists NFCB
    member stations throughout the country through community service
    grants. Community service grants are the core way that CPB uses to
    support radio stations--particularly targeted to stations offering the
    first public radio service to a community in a rural area, or to
    stations serving particular demographic constituencies. CPB's focus on
    these areas is critical to ensuring that public radio does not focus
    solely on higher-income audiences, but serves every American no matter
    their background or their location. These targeted 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. CPB 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 importantly,
    the insulation that advance funding provides is of critical importance
    in eliminating both the risk of and the appearance of undue
    interference with and control of public broadcasting.
        Community radio supports CPB activities in facilitating programming
    to Native American, Latino, and African-American radio stations. CPB
    has played a critical role in providing support and assistance to radio
    stations serving communities of color, particularly communities that
    could be better served by noncommercial radio. While CPB has long
    supported television programming focused on underserved communities,
    its programs for radio are newer and are very welcome. Given the
    importance and accessibility of radio in many underserved communities,
    NFCB urges the subcommittee to endorse the long-term viability of these
    radio minority consortia.
        Specifically, with important support from CPB, Native Public Media
    (NPM) has burst on to the scene to ensure that Native Americans have
    access to noncommercial broadcast and new technologies alike. NPM has
    worked in the last few years to facilitate applications for
    noncommercial radio stations by almost 40 applicants from tribal and
    native entities, bringing many of these service areas within the reach
    of a public radio signal for the first time. NPM has undertaken
    research to identify the spectrum allocations currently serving Indian
    country in order to target better service in the future, releasing a
    report called The New Media, Technology and Internet Use in Indian
    Country: Quantitative and Qualitative Analyses, which included a usage
    survey and case study that contains the first valid and credible data
    on Internet use among Native Americans. In addition, NPM was able to
    play a critical role in ensuring that tribal entities have the ability
    to obtain new radio stations in the future by successfully
    demonstrating to the FCC the need and legal justification for a tribal
    priority in radio.
        In addition, in the last year the newest minority consortium has
    been started--the Latino Public Radio Consortium. The Latino Public
    Radio Consortium is an organization that represents and supports 33
    public radio stations. It recognizes that Latinos are under-represented
    in the Nation's public broadcasting institutions, decisionmaking
    structures, that there is little programming in English or in Spanish
    produced by Latinos or with a Latino focus and, as a consequence,
    Hispanics are vastly underrepresented among public radio's news and
    public affairs audiences.\1\ To illustrate, a study by Station Resource
    Group's Grow the Audience project showed that, for public radio to
    acquire a representative share of the college-educated market for
    Latinos, it would need to triple its audience.\2\
    ---------------------------------------------------------------------------
        \1\ Latino Public Radio Consortium, Brown Paper, p.1 available at
    http://www.latinopublic radioconsortium.org/index.php?s=41.
        \2\ Station Resource Group, Grow the Audience, Listening by Black
    and Hispanic College Graduates (2008) at p. 17, available at http://
    www.srg.org/GTA/GTA%20Black%20Hispanic%20 Report.pdf.
    ---------------------------------------------------------------------------
        During this funding year the Consortium has established the
    communications and governance structure to enable the Hispanic stations
    to support each other and to develop additional resources. An important
    new project that is indicative of future work is the development of
    Historias, a partnership with Story Corps, a national oral history
    project of the Library of Congress and public radio. Through this
    collaboration, Story Corps Historias will gather and record 900
    individual interviews with Latinos around the country.
        This year CPB is funding new services for African-American public
    radio stations designed to improve and increase public media's service
    to the American public. NFCB believes that this project, like the other
    consortia, is vital to ensure that all Americans benefit from public
    funds and the breadth and depth of public radio. In addition to the
    minority consortia, CPB supports Satelite Radio Bilingue which 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. CPB also supports Native Voice One (NV1), which
    is distributing politically and culturally relevant programming to
    Native American stations.
        Community radio supports $59.5 million in fiscal year 2011 for the
    conversion to digital technology. While public television's digital
    conversion needs were 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.
    This development of second and third audio channels will potentially
    double or triple the service that public radio can provide listeners,
    particularly in unserved and underserved communities. In addition,
    public radio is in great need of CPB's leadership and resources to
    transition to new media platforms, in particular through such projects
    as the American Archive, which will make existing programming
    accessible to all and on all platforms.
        Community radio supports CPB's funding for rural stations and
    assistance with new technologies. 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 so that 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.
        A good example of CPB's role is the Public Media Innovation grant
    CPB gave KAXE, one of NFCB's rural members, a chance to experiment with
    the concept of becoming ``a web operation that owned a radio station.''
    PMI described this project as one of the most visionary proposals they
    funded. As part of the grant, KAXE began the development of Northern
    Community Internet, which would provide hyper-local news content to
    more than a dozen communities in northern Minnesota. Through this
    project, KAXE learned many important things about how to create content
    that is relevant and accessible across a Web site, radio station, and
    social media. The journalists involved continue to be very interested
    in the project, even though the current pilot is over.
        Community radio supports CPB programs focused on ensuring public
    radio is able to fulfill its important mission of public safety during
    emergencies. CPB funding has supported an important new project led by
    NFCB called Station Action for Emergency Readiness (SAFER). NFCB, in
    partnership with NPR and with support from CPB, has developed a step-
    by-step manual that stations can use to develop and/or supplement their
    own emergency readiness plans; a set of digital tools that stations can
    embed in their own Web sites to keep community members informed; and
    links to national and local resources that can supplement station's
    coverage. This project was inspired by the experience of NFCB member
    WWOZ in New Orleans as a result of Katrina and was furthered by the
    work of NFCB member KWMR in Point Reyes Station, California. KWMR is
    small and local community and provided absolutely critical life-saving
    information to its community during terrible floods of 2004-2005.
        Community radio supports CPB's role as a convener that can address
    questions and important future trends across all public media. CPB
    plays an extremely important role in the public and Community Radio
    system: it convenes 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.
        Thank you for your consideration of our testimony.
                                     ______

    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 the $2.4 billion for the
    Consolidated Health Centers Program in fiscal year 2011, as included in
    the administration's budget proposal.
        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 HCH Program--administered by the Health Resources and
    Services Administration (HRSA)--currently supports 207 HCH projects in
    all 50 States, the District of Columbia, and Puerto Rico. Congress
    established Health Care for the Homeless 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 more than 1 million
    patients in 2009--a sizable number, but far below the estimated 4
    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, to include through the American Recovery and
    Reinvestment Act of 2009. 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.
        Investments in Community Health Centers contained the Patient
    Protection and Affordable Care Act will also be a significant tool that
    will help clinics grow to meet the needs of patients seeking primary
    care, especially as the Medicaid expansion provisions are enacted in
    2014. This Medicaid expansion will be a greatly needed improvement for
    our homeless patients, since most are currently ineligible for
    coverage.
        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, the
    unemployment rate was 9.7 percent in March 2010. Given the prevalence
    of employer-sponsored health coverage, high unemployment leaves many
    Americans without health coverage, thus creating a greater need for
    safety net services provided by community health centers.
        Fiscal Year 2011 Appropriations.--In recognition of the growing
    need for primary healthcare services, the House Committee on
    Appropriations along with other Members of Congress has been supportive
    of strengthening and expanding community health centers. In the
    President's fiscal year 2011 budget proposal, the Community Health
    Center program receives $2.4 billion--$290 million above the fiscal
    year 2010 appropriation. This includes a total of $209 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 the $2.4 billion for the Community
    Health Center program (including $209 million for the HCH program), as
    contained in the administration's fiscal year 2011 budget proposal.
        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 Kidney Foundation

        The National Kidney Foundation (NKF) appreciates the opportunity to
    present public witness testimony for the written record in support of
    fiscal year 2011 funding for the Centers for Disease Control and
    Prevention.
        Kidney disease is the ninth leading cause of death in the United
    States. More than 26 million American adults are estimated to have some
    level of chronic kidney disease (CKD), yet most of them are
    undiagnosed. Early detection and treatment can prevent or slow the
    progression to irreversible kidney failure, or end-stage renal disease
    (ESRD). Many do not even reach end stage; late-stage CKD patients are
    far more likely to die of cardiovascular disease than to reach ESRD,
    and early detection is beneficial here also.
        Approximately 70 percent of new ESRD cases are directly
    attributable to diabetes or hypertension (with diabetes alone the cause
    of nearly half of all new cases annually). Furthermore, ESRD increases
    dramatically with age, and the prevalence among racial and ethnic
    minorities is much higher than among whites. Medicare covers dialysis
    or transplantation regardless of age or other disability (the only
    disease-specific coverage under the program) and the ESRD Program has
    saved millions of lives. However, the cost is substantial and
    disproportionate to the Medicare population. Less than 7 percent of the
    Medicare population carries a diagnosis of CKD, but they account for 21
    percent of Medicare expenditures.
        Despite the social and economic impact, no national public health
    program focusing on early detection and treatment of CKD existed until
    2005, when Congress provided funding for fiscal year 2006 to initiate a
    Chronic Kidney Disease Program at the CDC. The CKD program, which has
    received approximately $2 million annually, will build capacity and
    infrastructure at CDC for a kidney disease public health program. The
    objectives of the initiative are to assess and monitor the burden of
    CKD and its risk factors; develop methods to identify high risk
    populations; develop public health strategies to prevent the
    development of CKD and reduce its progression to kidney failure; and,
    develop models to assess the economic burden of CKD.
        In 2008 and 2009, the CDC and NKF collaborated on a demonstration
    project to detect individuals with or at high risk of CKD. The CKD
    Health Evaluation and Risk Information Sharing project (CHERISH) uses
    diabetes, hypertension, and age (older than 50) as risk factors to
    select participants for the screenings. Eight screenings of more than
    800 individuals in four States detected CKD in over one-quarter of the
    individuals, who demonstrate the need for better risk factor control of
    high blood pressure, diabetes, and high cholesterol. Awareness of
    kidney disease remains very low.
        Early detection and intervention of chronic kidney disease is not
    difficult and intervention tools to treat early CKD are widely
    available. The level of progression to chronic kidney failure or ESRD
    and the rate of premature cardiovascular death are unacceptable.
    Continued support, as requested by the administration in its 2011
    budget request, will promote comprehensive public health approaches in
    CKD by the CDC, including screening, surveillance, economic analysis,
    coordination with ongoing internal activities (cardiovascular disease
    and stroke prevention, diabetes, obesity, family history/genetics,
    communicable disease such as hemodialysis catheter infections),
    interagency collaboration (NIH, AHRQ, and HHS) and ultimately
    implementation through state departments of health to impact care,
    improve outcomes and reduce costs.
                                     ______

             Prepared Statement of the National Minority Consortia

        The National Minority Consortia (NMC) submits this statement on the
    fiscal year 2013 appropriation for the Corporation for Public
    Broadcasting (CPB). The NMC is a coalition of five national
    organizations dedicated to bringing the unique voices and perspectives
    from America's diverse communities into all aspects of public
    broadcasting and to other media, including content transmitted
    digitally over the Internet. The role we fulfill in this regard has
    been crucial to public broadcasting's mission for more than 30 years.
    We are unique as organizations and as a coalition of organizations in
    the services we provide in access, training, and support for important
    and timely public interest content to our communities and to public
    broadcasting. We ask the subcommittee to:
      --Direct CPB to increase its efforts for diverse programming with
            commensurate increases for minority programming and for
            organizations and stations located within underserved
            communities;
      --Direct CPB to establish a percentage basis for biennial funding of
            the NMC to permit long-range financial and strategic
            planning;\1\
    ---------------------------------------------------------------------------
        \1\ Currently funding for the NMC, in the aggregate, represents
    only 1.2 percent of CPB's request. We suggest increasing that
    percentage to an amount equal to not less than 20 percent of the amount
    requested for television programming, or approximately $20 million, to
    be split equally among the five groups listed here and beginning
    immediately upon enactment of this legislation.
    ---------------------------------------------------------------------------
      --Direct CPB to establish an annual ``report card'' on diversity to
            track efforts to better represent the full breadth of the
            American people and their experiences through public
            television, public radio and nonprofit media online;
      --Direct CPB to publish on the Internet clear and enforced guidelines
            for all CPB-directed funding, including funds jointly
            administered by PBS and NPR, and end the closed-door funding
            processes historically in place, especially as the current
            practices favor existing relationships and can be seen as
            biased against minority applicants, in particular.
        Report Language.--We ask for report language, specifically an
    addition to report language from the fiscal year 2006 Appropriations
    Act (and also included in the fiscal year 2007 Senate report), which
    recognizes the contribution of the NMC and directs that the CPB
    partnership with us be expanded. The Report stated:

        ``The Committee recognizes the importance of the partnership CPB
    has with the National Minority Public Broadcasting Consortia, which
    helps develop, acquire, and distribute public television programming to
    serve the needs of African American, Asian American, Latino, Native
    American, Pacific Islander, and many other viewers. As many communities
    in the Nation welcome increased numbers of citizens of diverse ethnic
    backgrounds, the local public television stations should strive to meet
    these viewers' needs. With an increased focus on programming to meet
    local community needs, the Committee encourages CPB to support and
    expand this critical partnership.'' (S. Rpt. 109-103, p. 298)

        We request that the above language be modified to direct CPB to
    increase its funding of the NMC and the various minority radio
    consortia to a level equal, in the aggregate, to 20 percent of funds
    allocated to television production.
        Fiscal Year 2013 Appropriation.--We support a fiscal year 2013
    advance appropriation for CPB of $604 million, which recognizes the
    need to develop content that reaches across traditional media
    boundaries, such as those separating television and radio. However, we
    feel strongly that should CPB receive this appropriation, CPB should be
    directed to engage in transparent and fair funding practices that
    guarantee all applicants equal access to these public resources. In
    particular, we urge Congress to direct CPB to insert language in all of
    its funding guidelines that encourages and rewards public media that
    fully represents and reaches a diverse American public.\2\
    ---------------------------------------------------------------------------
        \2\ According to the 2008 Public Radio Tech Survey, 90 percent of
    public radio listeners are White. Of those, 84 percent are college
    educated, with 48 percent having graduate degrees. This compares to
    just 9 percent of Americans who have postgraduate degrees. It is
    therefore mandatory that we prioritize actually ``reaching'' a diverse
    audience of Americans and not simply reflecting diverse and often
    misleading staffing numbers to measure public media's effectiveness in
    serving all of the American taxpayers that fund CPB.
    ---------------------------------------------------------------------------
        While public broadcasting continues to uphold strong ethics of
    responsible journalism and thoughtful examination of American history,
    life and culture, including the ways we are a part of a global society,
    it has not kept pace with our rapidly changing public as far as
    diversity is concerned. Members of minority groups continue to be
    underrepresented on both the programming and oversight levels within
    public broadcasting as well as on the content production side. There
    are fewer than five executives of diverse background at the highest
    levels in the three leading organizations within public broadcasting.
    This is unacceptable in America today, where minorities comprise more
    than 35 percent of the population.
        Public broadcasting has the potential to be particularly important
    for our Nation's growing minority and ethnic communities, especially as
    we transition to a broadband-enabled, 21st century workforce that
    relies on the skills and talent of all of our citizens. While there is
    a niche in the commercial broadcast and cable world for quality
    programming about our communities and our concerns, it is in the public
    broadcasting sphere where minority communities and producers should
    have more access and capacity to produce diverse high-quality
    programming for national audiences. We therefore, urge Congress to
    insert strong language in this act to ensure that this is the case and
    that these opportunities are made available to minorities and other
    underserved communities.
        About the NMC.--With primary funding from the CPB, the NMC serves
    as an important component of American public television as well as
    content delivered over the Internet. By training and mentoring the next
    generation of minority producers and program managers as well as
    brokering relationships between content makers and distributors (such
    as PBS, APT, and NETA), we are in a perfect position to ensure the
    future strength and relevance of public television and radio television
    programming from and to our communities. However, these efforts are
    vulnerable because of chronic underfunding and lack of meaningful and
    ongoing representation within CPB's decisionmaking processes. This
    instability, coupled with what is essentially a decrease in our funding
    over time, are the primary reasons that have led to a public media that
    has become less diverse over the past 5 years.\3\
    ---------------------------------------------------------------------------
        \3\ CPB funding for the NMC remained flat for 13 years until fiscal
    year 2008, at approximately $1 million per year per consortia. At that
    time, we received a one-time increase of $150,000 per organization. In
    fiscal year 2009, we received another one-time increase of
    approximately $500,000 each, but have been told that does not reflect a
    permanent increase. Over this same 13-year period, CPB's budget nearly
    doubled.
    ---------------------------------------------------------------------------
        This is obviously not the case in the rest of America. With
    minority populations already estimated at more than 35 percent of the
    U.S. population, it is more important that our public institutions
    reflect this reality.
        Individually, each NMC organization is engaged in cultivating
    ongoing relationships with the independent producer community by
    providing technical assistance and program funding, support and
    distribution. Often the funding we provide is the initial seed money
    for a project, thus allowing it to develop. We also provide numerous
    hours of programming to individual public television and radio
    stations, programming that is beyond the production reach of most local
    stations. To have a real impact, we need funding that recognizes and
    values the full extent of minority participation in public life.
        While the NMC organizations work on projects specific to their
    communities, the five organizations also work collaboratively. An
    example of a joint production in which the NMC provided the initial
    seed money is ``Unnatural Causes: Is Inequality Making Us Sick?'', a
    multi-part series that uncovers the roots of racial and socio-economic
    disparities in health and spotlights community initiatives to achieve
    health equality. Our seed money enabled the project to go forward and
    to attract additional funding. We are also co-producers of and
    presenters in this series, which originally aired in 2008 and was
    rebroadcast just this year. Additionally, we jointly funded an online
    initiative around the Presidential election in 2008 and continue to
    explore as a group other topics of national importance.
        CPB Funds for the NMC.--The NMC receives funds from two portions of
    the CPB budget: organizational support funds from the Systems Support
    and programming funds from the Television Programming funds. The
    organizational support funds we receive are used for operations
    requirements and also for programming support activities and for
    outreach to our communities and system-wide within public broadcasting.
    The programming funds are re-granted to producers, used for purchase of
    broadcast rights and other related programming activities. Each
    organization solicits applications from our communities for these
    funds. A brief description of our organizations follows:
        Center for Asian American Media.--CAAM's mission is to present
    stories that convey the richness and diversity of Asian-American
    experiences to the broadest audience possible. We do this by funding,
    producing, distributing, and exhibiting works in film, television, and
    digital media. Over our 25-year history we have provided funding for
    more than 200 projects, many of which have gone on to win Academy, Emmy
    and Sundance awards, examples of which are Daughter from Danang; Of
    Civil Rights and Wrongs: The Fred Korematsu Story; and Maya Lin: A
    Strong Clear Vision. CAAM presents the annual San Francisco
    International Asian American Film Festival and distributes Asian
    American media to schools, libraries, and colleges.
        Latino Public Broadcasting (LPB).--LPB supports the development,
    production, and distribution of public media content that is
    representative of Latino people, or addresses issues of particular
    interest to Latino Americans. LPB provides a voice to the diverse
    Latino community throughout the United States. Since its creation in
    1998 by Edward James Olmos, LPB has provided more than 200 hours of
    programming to public television, including Roberto Clemente, the
    Sundance award winners Farmingville and El General, and Emmy-nominated
    The Life and Times of Frida Kahlo. LPB has organized more than 100
    workshops for the advancement of Latino producers and launched the
    first Latino anthology series on public television, VOCES, which aired
    its second season in 2009 on PBS stations across the country. LPB has
    received the Imagen Award and the National Council of La Raza's Alma
    Award.
        The National Black Programming Consortium (NBPC).--NBPC develops,
    produces, and funds television and more recently audio and online
    programming about the Black experience for American public media
    outlets. Since its founding in 1979, NBPC has provided hundreds of
    broadcast hours documenting African- American history, culture, and
    experience to public television and launched major initiatives that
    have brought important public media content to diverse audiences. In
    2006, NBPC launched the New Media Institute (NMI) a program designed to
    train makers of public media to provide real value to communities using
    digital platforms. Currently, NBPC is preparing to launch the Public
    Media Corps, a highly visible, national, broadband-based program
    designed to extend the reach of taxpayer funded diverse content into
    the digital realm, to recruit the next generation of content makers,
    innovators and other stakeholders coming from all of America's
    communities, and to empower all Americans with relevant, critical, and
    timely information.
        Native American Public Telecommunications (NAPT).--NAPT shares
    Native stories with the world through support of the creation,
    promotion, and distribution of Native media. Founded in 1977, through
    various media-public television and radio, and the Internet-NAPT brings
    awareness of Indian and Alaska Native issues. Through the CPB-funded
    Production Fund, 5 to 10 new projects are supported each year. Last
    year, we worked with American Experience in the award winning We Shall
    Remain, a five-part Native history series. NAPT operates the AIROS
    Native Network, a 24/7 Internet radio station that features music,
    news, interviews, documentaries, and audio theater. We also feature
    downloadable podcasts with Native filmmakers, musicians, and tribal
    leaders. VisionMaker Video is now the premier source for quality Native
    educational and home videos. Profits made from video sales are invested
    in new NAPT productions. All aspects of our programs encourage the
    involvement of young people to learn more about careers in the media--
    to be the next generation of storytellers. Through our location at the
    University of Nebraska--Lincoln, we offer student employment,
    internships, and fellowships. Reaching the general public and the
    global market is the ultimate goal for the dissemination of Native-
    produced media.
        Pacific Islanders in Communications (PIC).--Since 1991, PIC has
    delivered programs and training that bring voice and visibility to
    Pacific Islander Americans. PIC presented the broadcast premier of the
    award-wining film, Whale Rider, on PBS--the story of young girl who
    confronts years of tribal tradition to fulfill her destiny as the
    leader of her people. Other PBS broadcasts include Time and Tide, about
    the devastating effects of global warming on the Pacific Islands and
    Polynesian Power the story of Pacific Islanders in the NFL. Currently
    PIC is developing a multi-part series, Expedition: Wisdom, in
    partnership with the National Geographic Society. PIC offers a wide
    range of development opportunities for Pacific Island producers through
    travel grants, seminars and media training. Producer training programs
    are held in the U.S. territories of Guam and American Samoa, as well as
    in Hawai`i, on a regular basis.
        Thank you for your consideration of our recommendations. We see new
    opportunities to increase diversity in programming, production,
    audience, and employment in the new media environment, and we thank
    Congress for support of our work on behalf of our communities.
                                     ______

              Prepared Statement of the National Marfan Foundation

        Mr. Chairman, thank you for the opportunity to submit testimony
    regarding the fiscal year 2011 budget for the National Heart, Lung and
    Blood Institute, the National Institute of Arthritis, Musculoskeletal
    and Skin Diseases, and the Centers for Disease Control and Prevention.
    The National Marfan Foundation is grateful for the subcommittee's
    strong support of the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention, 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.

                FISCAL YEAR 2011 APPROPRIATIONS RECOMMENDATIONS

    National Institutes of Health
        Mr. Chairman, NMF joins with other voluntary patient and medical
    organizations in recommending an appropriation of $35 billion for the
    National Institutes of Health in fiscal year 2011. This level of
    funding will ensure continued expansion of research on rare diseases
    like Marfan syndrome and build upon the significant investment provided
    to the NIH in the American Recovery and Reinvestment Act.
    National Heart, Lung and Blood Institute
                Pediatric Heart Network Clinical Trial
        NMF applauds the National Heart, Lung and Blood Institute 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.
        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 the
    growth factor TGF-beta plays 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.
        Over the past 4 years, more than 500 Marfan syndrome patients (age
    6 months to 25 years) have been enrolled in this study. Patients are
    randomized onto either losartan or atenolol (a beta blocker that is the
    current standard of care for Marfan patients with an enlarged aortic
    root). We are on schedule to meet the trial's enrollment target of 604
    patients by the end of this year. This is a noteworthy accomplishment
    in itself given the rarity of Marfan syndrome. We anxiously await the
    results of this first-ever clinical trial for our patient population.
    It is our hope that losartan will emerge as the new standard-of-care
    and greatly reduce the need for surgery in at-risk patients.
        Mr. Chairman, NMF is proud to actively support the losartan
    clinical trial in partnership with the Pediatric Heart Network.
    Throughout the life of the trial we have provided 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.
                Evaluation of Surgical Options for Marfan Syndrome Patients
        Mr. Chairman, we are grateful for the subcommittee's
    recommendations in the fiscal year 2010 bill encouraging NHLBI to
    support research on surgical options for Marfan syndrome patients.
        For the past several years, the NMF has supported an innovative
    study looking at outcomes in Marfan syndrome patients who undergo
    valve-sparing surgery compared with valve replacement. Initial findings
    were published last year in the Journal of Thoracic and Cardiovascular
    Surgery. Some short term questions have been answered, most importantly
    that valve-sparing can be done safely on Marfan patients by an
    experienced surgeon. The consensus among the investigators however is
    that long-term durability questions will not be answered until patients
    are followed for 10 years.
        As a result, the principal investigators involved in the study
    recently submitted an RO-1 grant proposal to the NHLBI seeking support
    for this effort. Confirming the utility and durability of valve sparing
    procedures will save our patients a host of potential complications
    associated with valve replacement surgery. We encourage the
    subcommittee to continue its support for this much-needed research in
    fiscal year 2011.
                NHLBI ``Working Group on Research in Marfan Syndrome and
                        Related Conditions''
        In 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.''

        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.
    National Institute of Arthritis and Musckuloskeletal and Skin Diseases
        NMF is proud of its longstanding partnership with the National
    Institute of Arthritis and Musculoskeletal and Skin Diseases. 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 trail continues to move 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 on this and other
    research.
    Centers for Disease Control and Prevention
        Mr. Chairman, we are very grateful to you and the subcommittee for
    your support of a Marfan syndrome awareness project currently being
    developed by the NMF and the CDC. 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.
    Our collaboration with the CDC in fiscal year 2010 will enable us to
    expand our outreach to the general public and healthcare providers and
    ultimately save lives.
        It is a hopeful time in our community as we reach out to at-risk
    populations about the cardiovascular complications associated with
    Marfan syndrome. Just last month, the American College of Cardiology
    and the American Heart Association issued landmark practice guidelines
    for the treatment thoracic aortic aneurysms and dissections. The NMF is
    promoting awareness of the new guidelines in collaboration with other
    organizations through a new Coalition known as TAD; the Thoracic Aortic
    Disease Coalition. We hope to partner with the CDC in fiscal year 2011
    to increase awareness of the guidelines so all patients will be
    adequately diagnosed and treated.
        For fiscal year 2011, NMF joins with the CDC Coalition in
    recommending an appropriation of $8.8 billion for the CDC. We also join
    with the Friends of the National Center on Birth Defects and
    Developmental Disabilities in recommending a funding level of $163.5
    million for NCBDD in 2011. NCBDD and its single-gene disorders program
    serve as the home within CDC for the Marfan syndrome community.
                                     ______

          Prepared Statement of the National Postdoctoral Association

        Mr. Chairman and members of the subcommittee: Thank you for this
    opportunity to testify in regard to the fiscal year 2011 funding for
    the National Institutes of Health (NIH). We are writing today in regard
    to support for postdoctoral scholars, specifically in support of the 6
    percent increase in NIH training stipends, as requested in the
    President's budget.
    Background: Postdocs are the Backbone of U.S. Science and Technology
        According to estimates by The National Science Foundation (NSF)
    Division of Science Resource Statistics, there are approximately 89,000
    postdoctoral scholars in the United States \1\. The NIH and the NSF
    define a ``postdoc'' as: An individual who has received a doctoral
    degree (or equivalent) and is engaged in a temporary and defined period
    of mentored advanced training to enhance the professional skills and
    research independence needed to pursue his or her chosen career path.
    The number of postdocs has been steadily increasing. The incidence of
    individuals taking postdoc positions during their careers has risen,
    from about 25 percent of those with a pre-1972 doctorate to 46 percent
    of those receiving their doctorate in 2002-2005 \2\. Moreover, the
    number of science and engineering doctorates awarded each year is
    steadily rising with doctorates awarded in the medical/life sciences
    almost tripling between 2003 and 2007 \3\.
    ---------------------------------------------------------------------------
        \1\ National Science Foundation Division of Science Resource
    Statistics. (January 2010). Science and engineering indicators 2010.
    Arlington, VA: National Science Board.
        \2\ Ibid.
        \3\ Ibid.
    ---------------------------------------------------------------------------
        Postdocs are critical to the research enterprise in the United
    States and are responsible for the bulk of the cutting edge research
    performed in this country. Consider the following:
      --Fully 43 percent of first authors on Science papers are
            postdocs.\4\
    ---------------------------------------------------------------------------
        \4\ Davis, G. 2005. Doctors without orders. American Scientist
    93(3, supplement). http://postdoc.sigmaxi.org/results/.
    ---------------------------------------------------------------------------
      --According to the National Academies, postdoctoral researchers
            ``have become indispensable to the science and engineering
            enterprise, performing a substantial portion of the Nation's
            research in every setting.'' \5\
    ---------------------------------------------------------------------------
        \5\ COSEPUP. (June 2001). Enhancing the postdoctoral experience for
    scientists and engineers. Washington, D.C.:National Academy Press. p.
    10.
    ---------------------------------------------------------------------------
      --Postdoctoral training has become a prerequisite for many long-term
            research projects.\6\ In fact, the postdoc position has become
            the de facto next career step following the receipt of a
            doctoral degree in many disciplines.
    ---------------------------------------------------------------------------
        \6\ COSEPUP. (June 2001). Enhancing the postdoctoral experience for
    scientists and engineers. Washington, D.C.: National Academy Press. p.
    11.
    ---------------------------------------------------------------------------
      --The retention of women and under-represented groups in scientific
            research depends upon their successful and appropriate
            completion of the postdoctoral experience.
      --Postdoctoral scholars carry the potential to solve many of the
            world's most pressing problems; they are the principal
            investigators of tomorrow.
        Unfortunately, postdocs are routinely exploited. They are paid a
    low wage relative to their years of training and are often ineligible
    for workman's compensation, disability insurance, paid maternity or
    paternity leave, employer-sponsored medical benefits, and retirement
    accounts.
        The NPA advocates for policies that support postdoctoral training.
    We advocate for policy change within the research institutions that
    host postdoctoral scholars. More than 150 institutions, including the
    National Institutes of Health (NIH) and the National Science Foundation
    (NSF) have adopted portions of the NPA's recommended practices.
    Problem: Postdoc Salaries/Stipends Don't Meet Cost-of-Living Standards
        The NIH leadership has been aware that these stipends are too low
    since 2001, after the publication of the results of the study Enhancing
    the Postdoctoral Experience for Scientists and Engineers conducted by
    The National Academies' Committee on Science, Engineering and Public
    Policy (COSEPUP). In response, the NIH pledged (1) to increase entry-
    level stipends to $45,000 by raising the stipends at least 10 percent
    each year and (2) to provide automatic cost-of-living increases each
    year thereafter to keep pace with inflation.
        Without sufficient appropriations from Congress, the NIH has not
    been able to fulfill its pledge. In 2007, the stipends were frozen at
    2006 levels and since then have only been raised twice: by 1 percent
    each year in 2009 and 2010. The 2010 entry-level training stipend is
    $37,740, the equivalent of a GS-8 position in the Federal Government
    (NIH Statement NOT-OD-10-047), despite the postdocs' advanced degrees
    and specialized technical skills. Furthermore, this stipend remains far
    short of the promised $45,000. Certainly, it is not reflective of any
    cost-of-living increases.
        The NPA's research has shown that the NIH training stipends are
    used as a benchmark by research institutions across the country for
    establishing compensation for postdoctoral scholars. In order to keep
    the ``best and the brightest'' scientists in the U.S. research
    enterprise, the NPA believes that it is extremely important that
    Congress appropriate funding for the 6 percent increase in training
    stipends.
        Please consider the following requests from scientists in other
    countries:
      --In 2009, the NPA was approached by a scientist from Qatar for help
            in recruiting U.S. scientists, and the Qatar Foundation is
            prepared to offer compensation and benefits that would far
            exceed those received by most postdocs in the United States.
      --Scientists from Canada, China, Japan, and Australia, among other
            countries, have been seeking the NPA's advice and have asked
            the NPA to establish partnerships with their organizations.
        And the following statistics:
      --Although the 2007 U.S. expenditures on Research and Development
            (R&D) exceeded that of any other country/region, from 1996 to
            2007, the U.S. R&D/GDP ratio held steady, while China's ratio
            doubled.\7\
    ---------------------------------------------------------------------------
        \7\ National Science Foundation Division of Science Resource
    Statistics. (January 2010). Science and engineering indicators 2010.
    Arlington, VA: National Science Board.
    ---------------------------------------------------------------------------
      --From 1996 to 2007, the R&D growth rate for the Asia/Pacific region
            increased from 24 to 31 percent, while the North American
            region's growth rate decreased from 40 to 35 percent.\8\
    ---------------------------------------------------------------------------
        \8\ Ibid.
    ---------------------------------------------------------------------------
      --From 1996 to 2007, the United States average annual growth of R&D
            expenditures averaged 5 percent, whereas China's average annual
            growth topped 20 percent.\9\
    ---------------------------------------------------------------------------
        \9\ Ibid.
    ---------------------------------------------------------------------------
        If the United States is to stay competitive in the global research
    enterprise, there needs to be continued, steady increases in NIH
    funding. If the U.S. research enterprise is to keep the best and
    brightest of postdoctoral scholars, there needs to be a significant
    increase in training stipends, sooner rather than later.
    Solution: Keep the NIH's Original Promise To Raise the Minimum Stipends
        In the 2010 NIH budget request, H.R. 3293 contained a 2-percent
    increase in the NRSA Stipend level. The Senate version of the bill
    contained no increase. In December 2009 the House-Senate Subcommittee
    reached a consensus and approved a 1-percent increase in the NRSA
    stipend level.
        The NPA would ask the subcommittee to recognize that such small
    increases are simply not enough. We ask the subcommittee to honor the
    President's request (NIH Summary of the Fiscal Year 2011 President's
    Budget):

        Ruth L. Kirschstein National Research Service Awards.--A total of
    $824.4 million, which is a 6 percent increase more than the fiscal year
    2010, will be directed to training stipends. This increase sends a
    clear message to both existing and ``would be'' scientists that their
    efforts are valued.

        The NPA believes it is fair, just, and necessary to reward the new
    scientists who will do the bulk of the research discovering cures for
    disease and developing new technologies to improve the quality of life
    for millions of people in the United States. Accordingly, we also
    recommend that the NIH:
      --Review the base stipend amount in terms of what it should be today,
            9 years after the pledge was made.
      --Provide cost-of-living adjustments for postdoctoral scholars
            located in regions with higher costs of living.
      --Develop a funding mechanism to provide supplemental funding for
            postdoctoral scholars on research grants that would help to
            ensure equitable compensation for all of the NIH-funded
            postdoctoral scholars.
        Finally, 10 years have passed since the National Academies' COSEPUP
    study on the postdoc. The NPA applauds the changes that have taken
    place to improve the postdoc situation but also recognizes that many
    serious issues remain unresolved that may, and most probably will,
    negatively affect the future U.S. research workforce. Thus, the NPA
    recommends that the Senate mandates and appropriate funds for a follow-
    up study that would provide information about the state of the
    postdoctoral community today.
        Thank you for your consideration.
                                     ______

             Prepared Satement of the National Psoriasis Foundation

                           INTRODUCTION AND OVERVIEW

        The National Psoriasis Foundation (the Foundation) appreciates the
    opportunity to submit written testimony for the record regarding fiscal
    year 2011 Federal funding needs for psoriasis and psoriatic arthritis
    research. The Foundation serves as the world's largest patient-driven,
    nonprofit, voluntary organization committed to finding a cure for and
    eliminating the devastating effects of psoriasis and psoriatic
    arthritis through research, advocacy, and education. Psoriasis--the
    Nation's most prevalent autoimmune disease, affecting as many as 7.5
    million Americans--is a genetic, chronic, inflammatory, painful,
    disfiguring, and life-altering disease that requires life-long,
    sophisticated medical intervention and care. Psoriasis imposes serious
    adverse effects on affected individuals and families, and 30 percent of
    people with psoriasis also develop psoriatic arthritis, which causes
    pain, stiffness, and swelling in and around the joints and can lead to
    permanent disability.
        The Foundation seeks to advance public and private efforts to
    improve treatment of psoriasis and psoriatic arthritis, 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
    normal lives with the highest possible quality of life. We work 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. To that end, we are most grateful
    that, in fiscal year 2010, Congress addressed the need to collect
    epidemiological data about psoriasis, by appropriating $1.5 million for
    researchers at the Centers for Disease Control and Prevention's (CDC)
    National Center for Chronic Disease Prevention and Health Promotion
    (NCCDPHP) to begin the process of developing a national psoriasis and
    psoriatic arthritis data collection and patient registry. Considerable
    progress has been made, in the short amount of time since the initial
    appropriation, to develop this registry in a thoughtful and deliberate
    manner. We respectfully request that Congress continue to support this
    important initiative, by appropriating $2.5 million in fiscal year 2011
    to allow this national psoriasis data collection initiative to move
    into the implementation phase. With additional fiscal year 2011
    funding, researchers can begin to collect data and increase our
    understanding of the co-morbidities, such as diabetes and heart attack,
    which are associated with psoriasis; examine the relationship of
    psoriasis to other public health concerns (e.g., smoking and obesity);
    and gain important insight into the long-term impact and treatment of
    psoriasis and psoriatic arthritis.
        In addition, the Foundation supports the President's fiscal year
    2011 budget request for a $1 billion increase in funding for the
    National Institutes of Health (NIH). The Foundation urges the
    subcommittee to provide a total fiscal year 2011 allocation of $32.2
    billion to NIH; this funding will help 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 expand on
    our nascent understanding of psoriasis and psoriatic arthritis
    patients' myriad co-morbid conditions.

                THE IMPACT OF PSORIASIS AND PSORIATIC ARTHRITIS

        Psoriasis typically first strikes between the ages of 15 and 25,
    but can develop at any time and usually lasts a lifetime. Total direct
    and indirect healthcare costs of psoriasis are calculated at more than
    $11.25 billion 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 still are 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
    psoriatic arthritis and other co-morbidities, such as Crohn's disease,
    diabetes, metabolic syndrome, obesity, hypertension, heart attack,
    cardiovascular disease, and liver disease. Recent studies have found
    that people with severe psoriasis have a 50 percent higher mortality
    risk and die 3 to 6 years younger than those who do not have psoriasis.
    Studies have found 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 effective, safe, long-term, and
    affordable therapies to allow them to live normally and improve the
    overall quality of their lives. Due to the nature of the disease,
    patients have to cycle through available treatments, which often stop
    working. While there are an increasing number of methods to control the
    disease, there is no cure. Often the treatments have serious side
    effects and can pose long-term risks for patients (e.g., suppress the
    immune system, deteriorate organ function, etc.). The lack of viable,
    long-term methods of control for psoriasis could be addressed through
    an increased Federal commitment to epidemiological, genetic, clinical
    and basic research. NIH and CDC research, taken together, hold the key
    to improved treatment of these diseases, better diagnosis of psoriatic
    arthritis and eventually a cure for psoriatic conditions.

         THE ROLE OF CDC IN PSORIASIS AND PSORIATIC ARTHRITIS RESEARCH

        Despite our increased understanding of the auto-immune
    underpinnings of psoriasis and its treatments, there is a dearth of
    population-based epidemiology data on psoriatic disease. The majority
    of existing epidemiological studies of psoriasis are based on case
    reports, case series and cross-sectional studies. Several analytical
    studies have been performed to identify potentially modifiable risk
    factors (e.g., smoking, diet, etc.) and some have yielded conflicting,
    or inconsistent, results. In addition, most case-controlled studies
    have been hospital-based, or specialty clinic-based, and, therefore,
    are limited in their value. Broadly representative population-based
    studies of psoriasis are lacking and needed.
        There is enormous opportunity to investigate the epidemiology of
    psoriasis, as there are still wide gaps in our knowledge of this
    disease. For example, there is a critical need to better understand the
    natural progress of chronic plaque psoriasis in order to identify which
    patients may experience spontaneous remissions and which patients may
    experience flares of their disease--and when and why. Large, broadly
    representative population-based studies can expand our understanding of
    the potential risk factors for developing psoriasis, and future
    interventional trials can determine if altering modifiable risk
    factors, such as smoking and obesity, leads to a lower risk of
    psoriasis. Research into triggers and causes of psoriatic disease is
    also likely to be useful in determining advancements for other auto-
    immune disorders. Finally, determining the relative importance of
    psoriasis, its treatments and its associated behaviors with the risk of
    developing co-morbidities--such as cardiovascular disease, cancer, and
    other diseases--will allow health professionals to better counsel
    patients and help them interpret long-term safety of novel therapies
    for psoriasis. The data collection and registry underway at the CDC
    will significantly advance our understanding of psoriatic disease and
    help answer some of the most pressing and perplexing questions facing
    researchers, clinicians, and patients.

               PSORIASIS AND PSORIATIC ARTHRITIS RESEARCH AT NIH

        It has taken nearly 30 years to understand that psoriasis is, in
    fact, not solely a disease of the skin but also of the immune system.
    In recent years, scientists have finally identified the immune cells
    involved in psoriasis. The last decade has seen a surge in our
    understanding of these diseases accompanied by new drug development.
    Scientists are poised as never before to make major breakthroughs.
        Within the NIH, the National Institute of Arthritis and
    Musculoskeletal and Skin Diseases, 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--or have funded--
    psoriasis research. Additionally, research activities that relate to
    psoriasis or psoriatic arthritis also have been undertaken at the
    National Cancer Institute; however, the Foundation maintains that many
    more NIH Institutes and Centers have a role to play, especially with
    respect to the myriad co-morbidities of psoriasis, as noted earlier.
    Although overall NIH funding levels improved for psoriasis research in
    fiscal year 2010, and funding was boosted through stimulus funding
    awards of $3 million in fiscal year 2009 and (an estimated) $2 million
    in fiscal year 2010, the Foundation remains concerned that, generally,
    total NIH funding is not keeping pace with psoriasis and psoriatic
    arthritis research needs. Further, the Federal Government's investment
    in psoriasis and psoriatic arthritis research is not commensurate with
    the impact of the disease. An analysis of longitudinal Federal funding
    data shows that, on average, NIH has spent approximately $1 per person
    with psoriasis--per year--over the past decade. We commend NIH for the
    increased fiscal year 2009 psoriasis research investment, which is
    currently estimated at approximately $1.70 per psoriasis patient.
    According to Psoriasis Foundation scientific advisors, approximately
    $37.5 million in NIH sponsored grants (about $5 per psoriasis patient
    per year) over 5 years is the Federal biomedical investment needed to
    achieve the next phase of progress toward improved psoriasis and
    psoriatic arthritis treatments and a cure.
        Adequate investment in psoriasis and psoriatic arthritis research
    in fiscal year 2011 and beyond is imperative, because a rare
    convergence of findings reached through various research studies only
    recently has elucidated new ideas about the mechanisms involved in
    psoriasis. 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; understanding the relationship of
    psoriasis to co-morbidities, such as heart attack, diabetes, increased
    mortality, and lymphoma; 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.

                            FUNDING REQUEST SUMMARY

        The Foundation recognizes that Congress and the Nation currently
    face unprecedented fiscal challenges. However, we also believe that
    greater fiscal year 2011 investment in biomedical and epidemiologic
    research at NIH and CDC will prove stimulative to the economy, by
    supporting researchers and academic institutions across the Nation.
    Further, researchers are poised, as never before, to 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 fiscal year 2011 funding allocations:
      --$2.5 million to the NCCDPHP within the CDC to continue to collect
            data on psoriasis and psoriatic arthritis and to implement a
            patient registry to improve the knowledge base of the
            longitudinal impact of these diseases on the individuals they
            affect, as well as increase understanding of disease triggers
            and co-morbid conditions; and
      --$32.2 billion to NIH and its Institutes and Centers with
            encouragement to expand their psoriasis and psoriatic arthritis
            research portfolios, with an emphasis on understanding more
            about common co-morbid conditions.

                                   CONCLUSION

        On behalf of the Foundation's Board of Trustees and the 7.5 million
    individuals who suffer from psoriasis and psoriatic arthritis, whom we
    represent, thank you for affording us the opportunity to submit written
    testimony regarding the fiscal year 2011 funding levels necessary to
    ensure that our Nation adequately addresses the needs of those who
    suffer with psoriasis and psoriatic arthritis, by improving therapies
    and eventually finding a cure. We believe that additional research
    undertaken at the NIH, coupled with epidemiologic efforts at the CDC,
    will help advance the Nation's efforts to improve treatments and
    identify a cure for psoriatic conditions. 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 fiscal year 2011 requests.
                                     ______

                  Prepared Statement of National Public Radio

        Thank you Chairman Harkin and Senator Cochran for the opportunity
    to support funding for public broadcasting. As NPR's president and CEO,
    I am testifying on behalf more than 850 public radio station partners,
    producers and distributors of public radio programming including
    American Public Media (APM), Public Radio International (PRI), the
    Public Radio Exchange (PRX), and many stations, both large and small
    that create and distribute content through the Public Radio Satellite
    System (PRSS).
        The public radio system and the tens of millions of Americans who
    listen to public radio programming every week are grateful, Chairman
    Harkin and Senator Cochran, for your decades of support for public
    broadcasting funding. We are also grateful for the additional $25
    million in funding provided by Congress last year to help stations
    offset the devastating financial impact of the country's economic
    crisis.
        Public radio's service to America is a story of continuing success,
    increasing dedication to news, journalism, public affairs and cultural
    programming, and expanding deployment of technology to improve our
    reach and impact. The nearly 34 million people tuning weekly into
    public radio programming is more than the total combined circulation of
    USA Today, the Wall Street Journal, The New York Times, Los Angeles
    Times, The Washington Post, and the next top 62 newspapers. Twenty-five
    NPR member stations in the top 30 markets rank in the top three most
    listened to stations for news. We are serving the American public
    through our broadcast stations, through our websites and Internet
    streaming and through applications for the iPhone, iPad, Droid,
    Blackberry, and other mobile devices.
        Consider the contributions made by these public radio stations
    whose local public service illustrates a system-wide commitment to
    community service:
      --Iowa Public Radio.--WOI AM and FM at Iowa State University, WSUI-AM
            and KSUI-FM at the University of Iowa, and KUNI-FM and KHKE-FM
            at the University of Northern Iowa are at the center of the
            newly consolidated State operation. With combined revenues of
            about $6 million annually and about 60 employees, roughly one-
            third of staff is devoted to news. Iowa Public Radio enhances
            civic and cultural connections across the State, strengthening
            communities and reflecting Iowa's sense of place. The weekend
            program Iowa Roots is aired statewide and features stories,
            music and talk with traditional artists from a variety of
            ethnic, geographic, occupational, and religious groups found in
            Iowa.
      --WXPR.--A community-licensed public radio station with studios in
            Rhinelander, WXPR serves about a 70-mile diameter area of
            Wisconsin, plus some bits of Michigan's Upper Peninsula. On the
            air since 1983, WXPR would never have been built, nor continued
            to serve the local community today without the continuing
            effort and generosity of many people in the Northwoods, plus
            the support of the Corporation for Public Broadcasting. WXPR is
            proud to provide the only radio service to large, sparsely
            populated rural areas of the State and is planning to expand
            coverage with two small repeater stations in Ironwood and Iron
            Mountain, Michigan.
      --Mississippi Public Broadcasting.--More than 127,000 Mississippians
            listen to MPB radio programming each week. More than 7,000
            blind and print-impaired people in the State use the Radio
            Reading Service of Mississippi through MPB which provides on-
            the-air readings of newspapers, books and magazines for persons
            who are unable to read the printed word, either because of
            visual handicaps or because of other physical handicaps, such
            as the inability to turn pages. MPB also serves as primary
            source of emergency information and news during crisis
            situations and was nationally recognized for its coverage
            during Hurricanes Gustav, Rita, and Katrina.
      --Minnesota Public Radio (MPR).--MPR operates a regional network of
            38 stations, covering Minnesota and parts of Wisconsin, the
            Dakotas, Michigan, Iowa, and Idaho. With 850,000 listeners each
            week, MPR has the largest audience of any regional public radio
            network and an expanding news department of 76 that is
            committed to improving local and regional coverage. MPR is a
            leader in classical and current music, and in a growing online
            news service, NewsQ.
        Stations like these, operating in every State and congressional
    district in the country, have become living embodiments of journalistic
    excellence, providing news, information, and cultural programming as
    other sources of media are contracting or retreating from local
    coverage. Many are the only locally owned and operated news
    organization in their community.
    Public Funds for Public Media
        The Corporation for Public Broadcasting (CPB) is an indispensable
    public funding source for public radio, accounting for roughly 12
    percent of an average public radio station's annual budget. The public
    broadcasting community is urging Congress to appropriate $604 million
    in 2-year advanced funding for fiscal year 2013.
        Journalism, news, information, and cultural programming are the
    cornerstones of public radio. And we are expanding in these areas, as
    many commercial news organizations contract. For example, public
    broadcasting stations have launched Local Journalism Centers (LJCs),
    combining funds from CPB and resources of 27 station entities to expand
    and improve journalism on the regional level. A primary goal of this
    initiative is to replace some of the traditional newsgathering capacity
    that has been lost amid the recent cutbacks, to take full advantage of
    developing technology in order to nourish and support the creation of
    new journalistic endeavors, and to ensure that there are no barriers to
    the distribution of public media content.
        A second recent joint initiative--Project Argo--is aimed at
    bringing expanding information on topics critical to communities and
    the Nation. This project, supported by CPB and the John S. and James L.
    Knight Foundation, provides a pilot group of 12 NPR stations with the
    resources to expand original reporting, and to curate, distribute and
    share online content about high-interest, specialized subjects. The 2-
    year pilot will help a dozen stations establish themselves as
    definitive sources of news on a topic selected by each one as most
    relevant to its community, such as city politics, the changing economy,
    healthcare, immigration, and education. These online reports will help
    fill the growing gap in local news offerings.
    Digital Funding
                Broadcasting's Digital Transition
        Broadcasting remains the principle distribution path for public
    radio programs. By the end of 2009, 463 stations were on the air with
    digital signals and more than 180 were multicasting (sending out two or
    more program streams) to their communities and listeners. Recent action
    by the Federal Communications Commission permitting public radio
    stations to boost HD signal power and provide expanded signal coverage
    creates another compelling reason to continue conversion funding. Many
    public radio stations will be seeking to boost power to better serve
    their communities in the coming year. Public broadcasting's funding
    request to continue our digital transformation in fiscal year 2011 is
    $59.5 million.
        Public Radio is using digital broadcasting as a tool to improve and
    broaden the reach of our programming to poorly served and un-served
    audiences. Radio reading services for the blind and deaf are becoming
    more accessible. Stations' service to communities during times of local
    and regional emergencies will benefit from digital broadcasting's more
    flexible and adaptable features. Digital broadcasting technology has
    enabled public radio stations to:
      --Provide Increased Local Services to Communities.--Stations are
            doubling and tripling programming offerings by multicasting
            through HD radio channels 2 and 3 options while super-serving
            existing and new groups of listeners.
      --Increase the Diversity of Programming by Providing Additional
            Content for Current Audience.--Use of HD radio channels 2 and 3
            means more news programming options, music and entertainment
            for listeners. The additional HD radio channels allow stations
            to add public affairs programming, educational instruction,
            international news, specialty music streams (jazz, classical,
            bluegrass, folk, rock, pop, international, etc.), and non-
            English language news.
      --Bring the Content Rich World of Public Radio to Blind and Deaf
            Audiences.--Relying often on small armies of volunteers, more
            than 120 stations provide 24-hour life-line service consisting
            of news education and readings from daily newspapers and
            magazine articles. Text information services such as emergency
            warnings and public service alerts may also be incorporated
            into the signal to enable display of this data.
                The New Network: Internet, Web and Mobile Platforms
        The 1967 Public Broadcasting Act Gave Enduring Reality to two
    Important Concepts.--Public funds for public broadcasting and the
    creation of a national, independent, not-for-profit network of
    television and radio broadcasters to serve the American public. More
    than four decades later, as public broadcasting's embrace of new
    technologies to serve and engage a wider and more diverse audience
    quickens its transformation into Public Media, a New Network for the
    digital era must be fostered. This New Network, built upon a Public
    Media Platform and utilizing the success and assets of public
    broadcasting as its core, will enable the next generation of content
    creation and distribution so that the American public can benefit from
    a larger vision of service from Public Media.
        Public radio is embracing the networked environment as a primary
    platform for audience and community service. To ensure that the
    American public continues to have free and universal access to public
    media content, high-speed and affordable broadband access is simply a
    necessity. Congressionally appropriated digital transition funds are
    essential to help ensure our success in providing a larger, more
    diverse and more inclusive service to the American public.
        Among the many station and national network initiatives underway,
    these are worth highlighting:
      --NPR's API.--In July 2008, NPR released an open Application
            Programming Interface, (API), a new pathway for content and
            functions to be widely shared on the web. NPR was one of the
            first major national media organizations to launch an API and
            it is an integral component of our mission to create a more
            informed public. It allows public radio stations and individual
            users to play a direct role in broadening web access to public
            radio content. The principle of openness encompassed in this
            web tool is a fundamental extension of the standards of free
            and universal access that are common to more traditional
            distribution of public radio content. Utilization of the API by
            stations enables the creation of content that more closely
            matches local community needs and interests, and facilitates
            diverse, more creative presentations of content, again to
            connect local information needs with content generated by
            other, collaborating communities.
      --The Public Media Platform.--Realizing public media's full potential
            requires a strategic investment in an information architecture
            that brings together fragmented digital assets. The Public
            Media Platform, under development by NPR in partnership with
            CPB, APM, PRI, PBS and the Public Radio Exchange (PRX), will
            allow content from a wide variety of independent and
            institutional producers to be combined in a common back-end
            system; and then for that content to be extracted and displayed
            on a wide variety of digital platforms based on business rules
            set by the producers. It is in essence and in practice the
            digital equivalent of the satellite distribution network that
            serves public radio's broadcast audience with the powers of
            search, social media tools, analytics, and data.
        Thank you again for continuing to support funding for public
    service media.
                                     ______

          Prepared Statement of the 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, 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 recommend that you maintain this
    support for NIH in fiscal year 2011 by providing an increase of 3.5
    percent more than fiscal year 2010. Within this proposed increase the
    NPRCs also respectfully request that the subcommittee provide the
    National Center for Research Resources (NCRR) with the resources to
    continue a robust construction, renovation, and instrumentation grant
    program as begun through the American Recovery and Reinvestment Act,
    which as explained in this testimony, would help to ensure that the
    NPRCs and other animal research resource programs continue to serve
    effectively in their role as a vital national resource. Additionally,
    the NPRCs request that Congress provide NCRR no less than $86,412,000
    for the NPRC P51 (base grant) program, the amount equal to the
    President's budget request. This program supports a portion of the
    operational costs of the eight NPRCs.
    The NPRCs' Role as a National Resource and in the NIH Director's Five
            Themes
        The NPRCs collaborate as a transformative and innovative network to
    support the best science and act as a resource to the biomedical
    research community as efficiently as possible. There is an exceptional
    return on investment in the NPRC program; $10 is leveraged for every $1
    of research support for the NPRCs. It is important to sustain funding
    for the NPRC program and the NIH as a whole to continue to grow and
    develop the innovative plan for the future of NIH. The NPRCs have a
    commitment from NCRR to develop a 5-year strategic plan to further
    enhance the capabilities of the NPRCs by building on current progress.
        NIH Director Dr. Francis Collins laid out his vision for the future
    of the agency in terms of five ``themes.'' The NPRCs as a consortium
    and as a resource to the biomedical research community currently play
    an important role in each of the five themes.
        High-throughput Technologies.--The NPRCs have been leading the
    development of a new Biomedical Informatics Research Network (BIRN) for
    linking brain imaging, behavior, and molecular informatics in nonhuman
    primate preclinical models of neurodegenerative disease. Using the
    cyberinfrastructure of the BIRN project for data-sharing, this project
    will link research and information to other primate centers, as well as
    other geographically distributed research groups.
        Translational Research.--Nonhuman primate models bridge the divide
    between basic biomedical research and implementation in a clinical
    setting. Currently, 7 of the 8 NPRCs are affiliated with and
    collaborate with the NCRR Clinical and Translational Science Awards
    (CTSA) Program through their host institution. Specifically, the
    nonhuman primate models at the NPRCs often provide the critical link
    between research with small laboratory animals and studies involving
    humans. As the closest genetic model to humans, nonhuman primates serve
    in the development process of new drugs, treatments, and vaccines, to
    ensure safe and effective use for the Nation's public.
        Using Science To Enable Healthcare Reform.--Animal models are an
    essential tool for bridging basic biomedical research and patient
    healthcare, and the NPRCs are a national resource which supports the
    achievement of this goal. 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.
        Global Health.--Primate models are necessary for research on global
    infectious diseases. Primates have served as the best model for various
    types of HIV research, and their availability for use has resulted in
    at least 14 licensed anti-viral drugs for treatment of HIV infection.
    Primate models will continue to be necessary to defend the world
    against possible future epidemics such as SARS, West Nile Virus, and
    avian flu; and they are critical to current efforts to create vaccines
    for Ebola and Marburg viruses, and for infectious agents that could be
    used by terrorists. They also serve as the best model for development
    of vaccines for tuberculosis and malaria.
        Although the number of chimpanzees essential to biomedical research
    is very few, chimpanzees remain the only valid research model for
    developing vaccines that prevent infection by the hepatitis C virus,
    from which millions of people worldwide suffer. Researchers do not
    embark upon the use of chimpanzees in research without due
    consideration, and are acutely aware of the ethical challenges and
    moral responsibilities of such research. But the fact remains that
    chimpanzee models have led to major medical advances; as a case in
    point, thanks to chimpanzee research, there are vaccines for hepatitis
    A and B.
        Reinvigorating the Biomedical Research Community.--The success of
    the U.S. Government's efforts in enhancing public health is contingent
    upon the quality of research resources that enable scientific research
    ranging from the most basic and fundamental to the most highly applied.
    Biomedical researchers have relied on one such resource--the National
    Primate Research Centers--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.
        The NPRCs are also supportive of getting students interested in the
    biomedical research workforce pipeline at an early age. For example,
    Yerkes NPRC supports a program that connects with local high schools
    and colleges in Atlanta, Georgia, and invites students to participate
    in research projects taking place at their field station location.
    The Need for Facilities Support
        As exemplified in the NPRCs' role in the future direction of NIH,
    the program is a vital resource for enhancing public health and
    spurring innovative discovery. In an effort to address many of the
    concerns within the scientific community regarding the need for funding
    for infrastructure improvements, the NPRCs support the continuation of
    a robust construction and instrumentation grant program at NCRR.
        The NPRCs thank Congress for appropriating $1.3 billion of NIH
    Recovery Act funds for construction (C06), renovation (G20), and
    instrumentation (S10) grants. The number of applications received by
    NCRR illustrated the pent up need for facilities funding in the
    biomedical research community. Some of our centers received awards but
    a number of primate centers (and many other animal facilities) did not.
        Animal facilities, especially primate facilities, are expensive to
    maintain and are subject to abundant ``wear and tear.'' In prior years,
    funding was set aside that fulfilled the infrastructure needs of the
    NPRCs and other animal research facilities. The NPRCs ask the
    subcommittee to provide an appropriation of no less than $125 million
    to NCRR for construction and renovation of animal facilities through
    C06 and G20 programs. Without proper infrastructure, the ability for
    animal facilities, including the NPRCs, to continue to meet the high
    demand of the biomedical research community will be unattainable.
        Thank you for the opportunity to submit this written testimony and
    for your attention to the critical need for primate research and the
    continuation of infrastructure support, as well as our recommendations
    concerning funding for NIH in the fiscal year 2011 appropriations bill.
                                     ______

              Prepared Statement of the National Respite Coalition

        Mr. Chairman, I am Jill Kagan, Chair of the ARCH National Respite
    Coalition, a network of respite providers, family caregivers, State and
    local agencies and organizations across the United States who support
    respite. Twenty-five State respite coalitions are also affiliated with
    the NRC. This statement is presented on behalf of the these
    organizations, as well as the Lifespan Respite Task Force, a coalition
    of more than 80 national and 100 State and local groups who supported
    the passage of the Lifespan Respite Care Act (Public Law 109-442).
    Together, we are requesting that the subcommittee include funding for
    the Lifespan Respite Care Program administered by the U.S.
    Administration on Aging in the fiscal year 2011 Labor, Health and human
    Service, and Education, and Related Agencies appropriations bill at its
    modest authorized level of $94.8 million. This will enable:
      --State replication of best practices in Lifespan Respite systems to
            allow all family caregivers, regardless of the care recipient's
            age or disability, to have access to affordable respite, and to
            be able to continue to play the significant role in long-term
            care that they are fulfilling today;
      --Improvement in the quality of respite services currently available;
      --Expansion of respite capacity to serve more families by building
            new and enhancing current respite options, including
            recruitment and training of respite workers and volunteers; and
      --Greater consumer direction by providing family caregivers with
            training and information on how to find, use and pay for
            respite services.

                               WHO NEEDS RESPITE?

        In 2009, a national survey found that more than 65 million family
    caregivers are providing care to individuals of any age with
    disabilities or chronic conditions (Caregiving in the U.S. 2009.
    Bethesda, MD: National Alliance for Caregiving and Washington, DC:
    AARP, 2009). It has been estimated that these family caregivers provide
    $375 billion in uncompensated care, an amount almost as high as
    Medicare spending ($432 billion in 2007) and more than total spending
    for Medicaid, including both Federal and State contributions and both
    medical and long-term care ($311 billion in 2005) (Gibson and Hauser,
    2008).
        While the aging population is growing rapidly, increasing the need
    for family caregiver support for this age group, the majority of family
    caregivers are caring for someone under age 75 (56 percent); 28 percent
    of family caregivers care for someone between the ages of 50-75, and 28
    percent are caring for someone under age 50, including children (NAC
    and AARP, 2009). Family caregiving is not just an aging issue, but also
    a lifespan issue for the majority of the Nation's families.
        Compound this picture with the growing number of caregivers known
    as the ``sandwich generation'' caring for young children as well as an
    aging family member. It is estimated that between 20 and 40 percent of
    caregivers have children under the age of 18 to care for in addition to
    a parent or other relative with a disability. And in the United States,
    6.7 million children, with and without disabilities, are in the primary
    custody of an aging grandparent or other relative.
        Families of the wounded warriors--those military personnel
    returning from Iraq and Afghanistan with traumatic brain injuries and
    other serious chronic and debilitating conditions--are at risk for
    limited access to respite. Together, these family caregivers are
    providing an estimated 80 percent of all long-term care in the United
    States. This percentage will only rise in the coming decades with an
    expected increase in the number of chronically ill veterans returning
    from war, greater life expectancies of individuals with Down's Syndrome
    and other disabling and chronic conditions, the aging of the baby boom
    generation, and the decline in the percentage of the frail elderly who
    are entering nursing homes.

                             WHAT IS RESPITE NEED?

        State and local surveys have shown respite to be the most
    frequently requested service of the Nation's family caregivers
    (Evercare and NAC, 2006). Yet respite is unused, in short supply,
    inaccessible, or unaffordable to a majority of the Nation's family
    caregivers. The 2009 NAC/AARP survey of caregivers found that a
    majority (51 percent) have medium or high levels of burden of care,
    measured by the number of activities of daily living with which they
    provide assistance, and 31 percent of all family caregivers were
    identified as ``highly stressed''. Half of all family caregivers (53
    percent) say that their caregiving takes time away from family and
    friends. Of those who sacrificed this time, 47 percent feel high
    emotional stress. Moreover, the 2009 survey found that despite the fact
    that among caregivers' most frequently reported unmet needs were
    ``finding time for myself'' (32 percent), ``managing emotional and
    physical stress'' (34 percent), and ``balancing work and family
    responsibilities'' (27 percent), only 11 percent of caregivers of
    adults 18+ make use of respite. This represents an increase from 5
    percent in 2004, but still far less than the percentage who could
    benefit from respite. Of six proposed national policies or programs
    presented to help caregivers, 3 in 10 selected respite as the preferred
    service (NAC and AARP, 2009). According to another survey in 2006, the
    percentage of family caregivers able to make use of respite in rural
    areas was only 4 percent (Easter Seals and NAC, 2006). In a study of a
    nationally representative profile of noninstitutionalized children ages
    0-17 who were receiving support from the Supplemental Security Income
    (SSI) program because of a disability, only 8 percent reported using
    respite, but three-quarters of families had unmet respite needs (Rupp,
    K, et al, 2005-2006).
        Barriers to accessing respite include reluctance to ask for help,
    fragmented and narrowly targeted services, cost, and the lack of
    information about how to find or choose a provider. Even when respite
    is an allowable funded service, a critically short supply of well-
    trained respite providers may prohibit a family from making use of a
    service they so desperately need.
        Twenty of 35 State-sponsored respite programs surveyed in 1991
    reported that they were unable to meet the demand for respite services.
    The 25 State coalitions and other National Respite Network members
    confirm that long waiting lists or turning away of clients because of
    lack of resources is still the norm. A study conducted by the Family
    Caregiver Alliance identified 150 family caregiver support programs in
    all 50 States and Washington, DC, funded with State-only or State/
    Federal dollars. Most of the funding comes from the Federal National
    Family Caregiver Support Program. As a result, programs are
    administered by local area agencies on aging, primarily serve the
    aging, and provide only limited respite, if at all. Only about one-
    third of the 150 identified programs serve caregivers who provide care
    to adults age 18-60 who must meet stringent eligibility criteria. As
    the report concluded, ``State program administrators see the lack of
    resources to meet caregiver needs in general and limited respite care
    options as the top unmet needs of family caregivers in the States.''
        While most families take great joy in helping their family members
    to live at home, it has been well documented that family caregivers
    experience physical and emotional problems directly related to
    caregiving responsibilities. Three-fifths of family caregivers age 19-
    64 surveyed recently by the Commonwealth Fund reported fair or poor
    health, one or more chronic conditions, or a disability, compared with
    only one-third of noncaregivers (Ho, Collins, Davis and Doty, 2005). A
    study of elderly spousal caregivers (aged 66-96) found that caregivers
    who experience caregiving-related stress have a 63 percent higher
    mortality rate than noncaregivers of the same age (Schulz and Beach,
    December 1999).
        For the millions of families of children with disabilities, respite
    has been an actual lifesaver. However, for many of these families,
    their children will age out of the system when they turn 21 and they
    will lose many of the services, such as respite, that they currently
    receive. In fact, 46 percent of U.S. State units on aging identified
    respite as the greatest unmet need of older families caring for adults
    with lifelong disabilities.
        Disparate and inadequate funding streams exist for respite in many
    States. But even under the Medicaid program, respite is allowable only
    through State waivers for home and community-based care. Under these
    waivers, respite services are capped and limited to narrow eligibility
    categories. Long waiting lists are the norm.
        Respite may not exist at all in some States for adult children with
    disabilities still living at home, or individuals under age 60 with
    conditions such as ALS, MS, spinal cord or traumatic brain injuries, or
    children with serious emotional conditions. In Tennessee, a young woman
    in her twenties gave up school, career and a relationship to move in
    and take care of her 53 year-old mom with MS when her dad left because
    of the strain of caregiving without any support.

                  RESPITE BENEFITS FAMILIES AND IS COST SAVING

        Respite has been shown to be a most effective way to improve the
    health and well-being of family caregivers that in turn helps avoid or
    delay out-of-home placements, such as nursing homes or foster care,
    minimizes the precursors that can lead to abuse and neglect, and
    strengthens marriages and family stability. A recent report from the
    U.S. Department of Health and Human Services prepared by the Urban
    Institute found that higher caregiver stress among those caring for the
    aging increases the likelihood of nursing home entry. Reducing key
    stresses on caregivers, such as physical strain and financial hardship,
    through services such as respite would reduce nursing home entry.
    (Spillman and Long, USDHHS, 2007)
        Budgetary benefits that accrue from respite are just as compelling.
    Delaying a nursing home placement for just one individual with
    Alzheimer's or other chronic condition for several months can save
    thousands of dollars. In an Iowa survey of parents of children with
    disabilities, a significant relationship was demonstrated between the
    severity of a child's disability and their parents missing more work
    hours than other employees. It was also found that the lack of
    available respite interfered with parents accepting job opportunities.
    (Abelson, A.G., 1999)
        Moreover, data from ongoing research at Oklahoma State University
    found that the number of hospitalizations, as well as the number of
    medical care claims decreased as the number of respite days increased
    (Fiscal Year 1998 Oklahoma Maternal and Child Health Block Grant Annual
    Report, July 1999). A Massachusetts social services program designed to
    provide cost-effective, family-centered respite care for children with
    complex medical needs found that for families participating for more
    than 1 year, the number of hospitalizations decreased by 75 percent,
    physician visits decreased by 64 percent, and antibiotics use decreased
    by 71 percent (Mausner, S., 1995).
        In the private sector, the most recent study by Metropolitan Life
    Insurance Company and the National Alliance for Caregivers found that
    U.S. businesses lose from $17.1 billion to $33.6 billion per year in
    lost productivity of family caregivers (MetLife and National Alliance
    for Caregiving, 2006). Offering respite to working family caregivers
    could help improve job performance and employers could potentially save
    billions

                    LIFESPAN RESPITE CARE PROGRAM WILL HELP

        The Lifespan Respite Care Act is based on the success of statewide
    Lifespan Respite programs in Oregon, Nebraska, Wisconsin, and Oklahoma.
    Arizona and Texas both recently passed State legislation to establish
    Lifespan Respite Programs, but Arizona's program was cut due to State
    budget shortfalls. Twelve States, including Arizona, began
    implementation in 2009 with the first wave of Federal Lifespan Respite
    funding.
        Lifespan Respite, which is a coordinated system of community-based
    respite services, helps States use limited resources across age and
    disability groups more effectively. Pools of providers can be
    recruited, trained and shared, administrative burdens can be reduced by
    coordinating resources, and savings used to fund new respite services
    for families who may not qualify for any existing Federal or State
    program.
        The first State Lifespan Respite programs in Oregon, Nebraska,
    Wisconsin, and Oklahoma provide best practices on which to build a
    national respite policy. The programs have been recognized by the
    National Conference of State Legislatures, which recommended the
    Nebraska program as a model for State solutions to community-based
    long-term care, the National Governors Association, and the President's
    Committee for People with Intellectual Disabilities. The White House
    Conference on Aging recommended Congressional support for the Lifespan
    Respite Care Act.
        The purpose of the law is to expand and enhance respite services,
    improve coordination, and improve respite access and quality. Under a
    competitive grant program, States are required to establish State and
    local coordinated Lifespan Respite care systems to serve families
    regardless of age or special need, provide new planned and emergency
    respite services, train and recruit respite workers and volunteers and
    assist caregivers in gaining access to services. Those eligible would
    include family members, foster parents or other adults providing unpaid
    care to adults who require care to meet basic needs or prevent injury
    and to children who require care beyond that required by children
    generally to meet basic needs.
        The Federal Lifespan Respite program is administered by the U.S.
    Administration on Aging, Department of Health and Human Services (HHS).
    AoA provides competitive grants to State agencies in concert with Aging
    and Disability Resource Centers working in collaboration with State
    respite coalitions or other State respite organizations. The program
    was authorized at $53.3 million in fiscal year 2009 rising to $95
    million in fiscal year 2011. Congress appropriated $2.5 million in
    fiscal year 2009 and again in fiscal year 2010. In fiscal year 2009, 12
    States received 36-month $200,000 grants to implement Lifespan Respite.
    In these States, that represents less than $.18 per caregiver.
        The administration recommended $5 million for Lifespan Respite as
    part of its Middle Class Initiative. We are heartened to see that
    support for family caregiving is recognized as a critical component of
    a typical family's economic and social well-being. However, the focus
    of the administration's request was on support for family caregivers of
    the aging population. While this is an issue of growing concern, we
    must not neglect that fact that at least half of the Nation's family
    caregivers are caring for someone with MS, ALS, traumatic brain or
    spinal cord injury, mental health conditions, developmental
    disabilities or cancer who are under the age of 60 and $5 million will
    not address their need for respite. This is also the population most
    likely to be ineligible for any existing State or Federal respite
    resources.
        No other Federal program mandates respite as its sole focus. No
    other Federal program would help ensure respite quality or choice, and
    no current Federal program allows funds for respite start-up, training,
    or coordination or to address basic accessibility and affordability
    issues for families. We urge you to include $94.8 million in the fiscal
    year 2011 Labor, Health and Human Services, and, Education, and Related
    Agencies appropriations bill so that Lifespan Respite Programs can be
    replicated in the States and more families, with access to respite,
    will be able to continue to play the significant role in long-term care
    that they are fulfilling today.
                                     ______

    Prepared Statement of the National REACH Coalition for the Elimination
                             of Health Disparities

        The National REACH Coalition represents more than 40 communities
    and coalitions in 22 States working to eliminate racial and ethnic
    health disparities and improve the health of African American, Asian
    Pacific Islander, Native American, and Latino populations and
    communities. The coalition is an outgrowth of the Racial and Ethnic
    Approaches to Community Health (REACH U.S.) 2010 initiative, started a
    decade ago by the Centers for Disease Control and Prevention (CDC).
    REACH programs are on the front lines, providing coordination and
    leadership for the advancement and translation of community-based
    participatory research into evidence-based practices, policies, and
    community empowerment.
        For the fiscal year 2011 funding cycle the National REACH Coalition
    encourages the Labor, Health and Human Services, and Education, and
    Related Agencies (Labor-HHS) Subcommittee to increase funding for the
    Racial and Ethnic Approaches to Community Health program to $60
    million, an increase of $20.356 million more than fiscal year 2010.
        The NRC gratefully acknowledges the strong bipartisan support that
    the Senate Subcommittee on Labor-HHS has provided to the REACH U.S.
    program in recent years, most REACH programs were not eligible for
    additional funding provided by the American Recovery and Reinvestment
    Act and yet are working in communities that are among the hardest hit
    by the recession. With significant budget challenges at the State/local
    levels, REACH programs provide an important safety net to help
    eliminate racial and ethnic health disparities and close the health
    equity gap.
        Chronic diseases are the Nation's leading causes of morbidity and
    mortality and account for 75 percent of every $1 spent on healthcare in
    the United States. Collectively, they account for 70 percent of all
    deaths nationwide. Thus, it is highly likely that nearly 3 of 4 persons
    living in your district will be likely to develop a chronic condition
    requiring long-term and costly medical intervention. Moreover, chronic
    diseases account for the largest health gap among racial and ethnic
    minority populations. African Americans have higher mortality rates for
    cardiovascular disease and stroke, and cancer of the lung, colon/
    rectum, breast, cervix, and prostate than Whites, American Indians/
    Alaska Natives, Asian/Pacific Islanders, and Hispanic Americans.
        REACH U.S. programs are working hard to eliminate these health
    disparities and many have proven success in their communities.
    Collectively as the National REACH Coalition, our programs have engaged
    hundreds of local coalition members and touched the lives of thousands
    of program participants in this nationwide campaign against health
    disparities. As a result, the REACH communities are testing, evaluating
    and implementing practice and evidence-based interventions that reduce
    the human and financial cost of these preventable diseases and
    associated risk factors by:
      --In South Carolina, the REACH Charleston and Georgetown Diabetes
            Coalition reports that a 21 percent gap in blood sugar testing
            between African Americans and whites has been virtually
            eliminated. Amputations among African-American males with
            diabetes have been reduced by more than 33 percent. Each
            avoided amputation avoids at least $40,000 in expenditures;
            expanding this program could substantially reduce South
            Carolina's annual diabetes-related financial burden of more
            than $900 million.
      --The REACH for Wellness program in Georgia's Atlanta Empowerment
            Zone reports that from 2002 to 2004 the percentage of adults
            who regularly participated in moderate to vigorous physical
            activity increased from 25.4 percent to 28.7 percent; the
            percentage who reported checking their total blood cholesterol
            increased from 69.1 percent to 79.7 percent, and the percentage
            of adults who smoked decreased from 25.8 percent to 20.8
            percent.
      --The REACH Alabama Breast and Cervical Cancer Coalition in Macon
            County reports that disparities in mammography screening
            between white and African American women decreased from 15
            percent to 2 percent from 1998 to 2003.
      --In Massachusetts, the Greater Lawrence Family Health Center, a
            REACH Center of Excellence in Eliminating Health Disparities,
            has been able to demonstrate long-term disparity reductions
            among Latinos on five measures of diabetic care and outcomes.
      --Data from the REACH Risk Factor Survey show that the REACH program
            is having a significant impact in key areas of risk reduction
            and disease management:
        --From 2001 to 2004, African Americans transitioned from being less
                likely to more likely than whites to have their cholesterol
                checked.
        --In REACH communities, the sizable gap in cholesterol screening
                between Hispanics and the national average is closing.
        --In REACH communities, the proportion of American Indians with
                high blood pressure who take medication increased from 67
                percent in 2001 to 74 percent in 2004.
        --Cigarette smoking among Asian men in REACH communities decreased
                from 35 percent in 2001 to 24 percent in 2004.
        REACH U.S. communities have spent the last decade leveraging CDC
    funding with public private partnerships in order to effectively
    address health disparities. Using innovative science-based approaches
    we have demonstrated that health disparities once considered expected
    are not intractable. REACH U.S. has provided a sound return on
    investment, but we could do a lot more. In 2007, more than 200
    communities applied for funding in the last CDC REACH U.S. program
    application cycle, but only 40 were funded. While we are extremely
    grateful for the $4 million increase REACH U.S. received in fiscal year
    2010, without additional support REACH U.S. will not be able to extend
    its successful, cost-effective evidence- and practice-based programs to
    communities bearing a disproportionate share of the national chronic
    disease burden.
        Providing a $20.356 million increase, for a total of $60 million in
    fiscal year 2011 for REACH U.S. programs will ensure investment and
    sustainability in the bread and butter of prevention and wellness
    programs--community-led and community-driven interventions.
    Furthermore, health disparities and health equity will continue to be
    addressed and REACH U.S. programs will have the ability to be expanded
    in our Nation's most underserved communities. We strongly urge the
    subcommittee to consider this request to strengthen the capacity of the
    REACH U.S. program.
        We thank you for this opportunity to present our views to this
    subcommittee. We look forward to working with you to improve the health
    and safety of all Americans.
                                     ______

       Prepared Statement of the National Recreation and Park Association

        Thank you Chairman Harkin, Ranking Member Cochran, and other
    honorable members of the subcommittee for the opportunity to submit
    written testimony on the importance of funding the Centers for Disease
    Control and Prevention's (CDC) Healthy Communities Program. We
    respectfully request funding of $30 million in the fiscal year 2011
    Labor, health and Human Services, and Education, and Related agencies
    appropriations bill.
        NRPA is a 501(c)3 national nonprofit organization with more than
    21,000 members. We represent both citizens and park and recreation
    professionals. Our mission is to advance parks, recreation and
    environmental conservation for the benefit of all people. Because we
    represent the public park and recreation agencies in the United States,
    we touch the lives of more than 300 million people in virtually every
    community. Park and recreation agencies play a major role in the fight
    against obesity and are poised and capable of doing even more through
    the creation of new cross-cutting partnerships that promote health
    lifestyle choices for children and adults.
        Our Nation currently faces an obesity epidemic that is claiming the
    lives of adults and children. According to the CDC, the obesity rate in
    children ages 6 to 11 doubled from 6.5 percent in 1980 to 17 percent in
    2006; and tripled among those ages 12 to 19 to 17.6 percent during the
    same time period. More than one-third of U.S. adults--more than 72
    million people--were obese in 2005-2006.
        Obesity also has a crippling effect on our Nation's economy and is
    largely responsible for the exuberant rise in healthcare costs. CDC
    reports that data from the 1998 and 2006 Medical Expenditure Panel
    Surveys (MEPS) revealed that obesity increased medical costs by 37
    percent from 1998 to 2006. A 2009 study released by RTI, a nonprofit
    research firm, showed that obese Americans cost the country about $147
    billion in weight-related medical bills in 2008, double what it was a
    decade ago. Obesity now accounts for about 9.1 percent of medical
    spending in our country.
        The obesity and chronic disease epidemics plaguing our Nation did
    not manifest themselves overnight. These epidemics grew to be national
    issues of concern by impacting one individual, one family, and one
    community at a time. A multitude of factors such as lack of physical
    activity, poor diet, and excessive tobacco and alcohol use have led to
    this national epidemic. The good news is that many of the health risk
    factors that contribute to the development of chronic disease and
    obesity are preventable. However, the only way we will truly reduce
    obesity is to employ a comprehensive strategy that addresses these
    factors where people live, work, learn and recreate. In order for us to
    effectively combat these epidemics, local communities must be armed
    with the necessary tools and resources to implement policy,
    environmental and systematic changes geared towards promoting increased
    physical activity, nutritious foods, and the prevention of chronic
    disease in children, youth, and adults.
        Investment in prevention and wellness was one of President Obama's
    eight core principles guiding healthcare reform. Congress also stressed
    the importance of prevention at the community level throughout the
    health reform debate and through inclusion of various prevention
    measures in the Patient Protection and Affordable Care Act and
    Education Affordability Reconciliation Act. The economics of community
    level prevention are clear. As noted by the Trust For America's Health,
    for 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, the country could save more than $16
    billion annually within 5 years. This is a return of $5.60 for every $1
    spent. Prevention programs provide proven returns on investment. We are
    asking this subcommittee to further invest in prevention through
    increased fiscal year 2011 appropriations for CDC's Healthy Communities
    Program.
        Through its Healthy Communities program, CDC facilitates the
    collaboration of local and State health departments, national
    organizations with extensive reach into communities and a wide range of
    community leaders and stakeholders to develop, activate and spread
    policy, systems and environmental changes that prevent chronic disease
    by changing behavior and increasing the opportunities for healthier
    lifestyles. These community leaders and stakeholders represent local
    elected officials, city and county health officials, tribal programs,
    parks and recreation departments, local YMCAs, health-related
    coalitions, and education, business, health, planning, and
    transportation sectors. This collaboration results in proven community-
    based programs and environmental changes that encourage people to be
    more physically active, improve nutrition, and abstain from tobacco
    use.
        To date, more than 240 communities have received funding and
    technical support through CDC's Healthy Communities Program which has
    resulted in measurable changes at the local level. An additional 170
    communities will receive funding to improve the health of their
    communities during the next 3 years.
        Davenport, Iowa has recently received Healthy Communities funding,
    and has allowed the formation of a broad coalition of stakeholders that
    has begun work to prevent chronic disease. In Davenport, Iowa the top
    five leading causes of death are heart disease (26.6 percent), cancer
    (23 percent), other conditions (19.7 percent), stroke (7.8 percent),
    and chronic lung/respiratory disease (6.3 percent). Efforts to reverse
    these trends include identifying means of increasing the usage of
    Davenport parks and trails; promoting healthier lifestyles in
    workplaces by engaging employers in encouraging employees to use stairs
    instead of elevators; making all Davenport parks tobacco-free; and
    increasing student wellness in Davenport schools by revising school
    wellness policies.
        Chicago, Illinois is a great example of the impact and success of
    the Healthy Communities program. The city has noted that 26 percent of
    their children and 25 percent of their adult populations are obese by
    national standards. Contributing to the poor health of this community
    is the lack of opportunities for physical activity and the fact that
    the west side of Chicago lacks grocery stores which has caused it to
    become a ``food desert''. This, in turn causes residents to utilize
    fast food chains and convenience stores as a main source of
    nourishment. Recognizing the health and financial implications of an
    obese population, Chicago is taking proactive steps to ensure a
    healthier a community. The park district has introduced new fitness
    classes in parks throughout the city and is now offering a minimum of
    60 minutes of moderate to vigorous activity for all children's programs
    offered through parks. Through the leadership of the Mayor's office, a
    healthy vending policy has been initiated at all park facilities and
    the park district is implementing community produce gardens which will
    be maintained by local youth. Additionally, smoking has been banned on
    all Chicago Park District Property, indoors and out including beaches.
    Thanks to funding provided through CDC's Healthy Communities program,
    the city of Chicago will be able to implement more policy, systems and
    environmental changes, such as these, to combat chronic disease and
    obesity throughout the city.
        Funding for the CDC's Healthy Communities program is vital to
    successfully combating chronic disease and obesity at the local level
    in communities across the country. Previous funding levels have been
    inadequate. The Healthy Communities program has gone from $46.6 million
    in fiscal year 2005 to only $22.7 million in fiscal year 2010. As a
    result, hundreds of eligible communities have applied for highly
    competitive projects but remain unfunded due to limited Federal
    resources.
        Given the health implications and the fiscal hardship associated
    with chronic disease and obesity, we can no longer afford to be a
    nation that simply treats the problem. Now, more than ever Congress
    must increase its investment in community prevention programs such as
    this. NRPA respectfully requests that this committee provide increased
    funding for CDC's Healthy Communities program to $30 million in the
    fiscal year 2011 appropriations bill.
        Thank you for this opportunity to submit testimony.
                                     ______

              Prepared Statement of the National Sleep Foundation

    Summary of Fiscal Year 2011 Recommendations
        Provide $2 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 fund additional States to collect essential national and State-
    specific surveillance data; to support targeted public awareness
    initiatives; to create training materials for healthcare professionals;
    and build and test public health interventions.
        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 healthcare 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 admit 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.
        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 7 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 twenty 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
    3 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 8 States to include an optional sleep module in
    their data collection efforts through the Behavioral Risk Factor
    Surveillance System (BRFSS). Recent analysis of the core data found
    that more than 1 in 10 Americans report having insufficient sleep or
    rest every day for the past 30 days. Significantly, sleep problems were
    found to be more prevalent in southeastern States in what is commonly
    referred to as the ``stroke belt.'' This region has an unusually high
    incidence of stroke, cardiovascular disease, diabetes, obesity,
    depression, and quality of life, which are associated with inadequate
    sleep quality and quantity. The CDC is currently recruiting up to 14
    States and hopes to expand the data collection to all 50 States if
    appropriate funding is obtained.
        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 supported and actively participated in
    NSF's ongoing national public awareness initiatives including National
    Sleep Awareness Week and Drowsy Driving Prevention Week. The year, with
    CDC's support and guidance, NSF launched a new initiative called Sleep
    Health and Safety Conference 2010 designed to educate clinicians and
    other healthcare professionals about sleep disorders in order to
    increase better diagnosis and treatment.
        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.
        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 aimed at promoting sleep as a
                health behavior, treatment of obstructive sleep apnea, and
                drowsy driving as well as the goals and activities of the
                National Sleep Awareness Roundtable.
        --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.
        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 subcommittee will provide funding of $2,000,000 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

        I am pleased to present the fiscal year 2011 budget request for
    NTID, one of eight colleges of RIT, in Rochester, New York. Created by
    Congress by Public Law 89-36 in 1965, we provide university technical
    and professional education for students who are deaf and hard-of-
    hearing, leading to successful careers in high-demand fields for a sub-
    population of individuals historically facing high rates of
    unemployment and under-employment. We also provide baccalaureate and
    graduate level education for hearing students in professions serving
    deaf and hard-of-hearing individuals. As of fall 2009, NTID served a
    total 1,474 students from across the nation, including 1,307 deaf and
    hard-of-hearing students and 167 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 42 years.

                                 BUDGET REQUEST

        As shown below, NTID's fiscal year 2011 budget request was
    $66,252,000 in operations and $3,640,000 in construction, for a total
    of $69,892,000; the President's request is $63,037,000 in operations
    and $1,640,000 in construction, for a total of $64,677,000.

                                         FISCAL YEAR 2011 BUDGET REQUEST STATUS
                                                [In thousands of dollars]
    ----------------------------------------------------------------------------------------------------------------
                                                                        Operations     Construction        Total
    ----------------------------------------------------------------------------------------------------------------
    NTID request....................................................          66,252           3,640          69,892
    President's request.............................................          63,037           1,640          64,677
                                                                     -----------------------------------------------
          Difference................................................           3,215           2,000           5,215
    ----------------------------------------------------------------------------------------------------------------

        For the last 2 fiscal years (2009 and 2010), NTID's operations
    budget has been level-funded at $63,037,000; the President's
    recommended budget for fiscal year 2011 would mark a third consecutive
    year of level funding.
        For these past 2 years, NTID has been able to absorb level-funding
    in operations primarily due to two factors: (1) a self-initiated
    budget-reduction/revenue enhancement campaign from fiscal year 2003
    through fiscal year 2007; and (2) a withholding of salary increased by
    RIT for fiscal year 2010. However, realized savings from the campaign
    now have been re-allocated and are no longer available, and RIT
    recently has announced a 2 percent salary increase for fiscal year
    2011.
        While NTID certainly would benefit from a budget increase to
    support upcoming strategic initiatives (see below), we understand the
    resource challenges facing the subcommittee this year. While an
    additional $1,640,000 beyond the President's recommended operations
    funding for fiscal year 2011 is needed, we are amenable to meeting this
    need by shifting funds designated in the President's 2011 budget from
    construction to operations. This would ensure NTID stays within the
    total allocation proposed in the President's 2011 budget of
    $64,677,000, and still fully meet our Operations needs. We will seek
    alternative funding for needed construction items.

                                   ENROLLMENT

        In fiscal year 2010 (fall 2009), we attracted the largest
    enrollment in our 42-year history. Truly a national program, NTID
    enrolls students from all 50 States. Our current enrollment is 1,474.
    Over the last 3 years our enrollment has increased 18 percent (224
    students). For fiscal year 2011, NTID anticipates maintaining this
    record high enrollment level. Our enrollment history over the last 5
    years is shown below:

                                                                                   NTID ENROLLMENTS: FIVE-YEAR HISTORY
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                       Deaf/hard-of-hearing students                                 Hearing students
                                                                     ----------------------------------------------------------------------------------------------------------------
                               Fiscal year                                                                                             Interpreting                                     Grand total
                                                                         Undergrad       Grad RIT          MSSE          Subtotal         program          MSSE          Subtotal
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    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
    2010............................................................           1,237              38              32           1,307             138              29             167           1,474
    ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

                            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 demonstrably positive effect on
    students' earnings over a lifetime, and results in a noteworthy
    reduction in dependence on Supplemental Security Income (SSI), Social
    Security Disability Insurance (SSDI), and public assistance 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 that graduating from NTID 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 withdrew before graduation. Students who withdrew 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 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 not admitted continued to
    participate in the SSI program. Graduates also accessed SSDI, an
    unemployment benefit, at far lesser rates than students who withdrew;
    by age 50, 34 percent of nongraduates were receiving SSDI, while 22
    percent of baccalaureate graduates and 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.

                STRATEGIC INITIATIVES BEGINNING FISCAL YEAR 2011

        NTID has just completed Strategic Decisions 2020, a strategic plan
    based on our founding mission statement. This statement sets forth our
    institutional responsibility to work with students to develop their
    academic, career, and life-long learning skills as future contributors
    in a rapidly changing world. It also recognizes our role as a special
    resource for preparing individuals who are deaf and hard-of-hearing,
    for conducting applied research in areas critical to the advancement of
    individuals who are deaf and hard-hard-of hearing, and for
    disseminating our collective and cumulative expertise.
        Strategic Decisions 2020 establishes key initiatives responding to
    future challenges and shaping future opportunities. These initiatives,
    scheduled for implementation beginning in fiscal year 2011, include:
      --Pursuing enrollment targets and admissions and programming
            strategies that will result in increasing numbers of our
            graduates achieving baccalaureate degrees and higher, while
            maintaining focus and commitment to quality associate-level
            degree programs leading directly to the workplace;
      --Improving services to under-prepared students through working with
            regional partners to implement intensive summer academic
            preparation programs in selected high-growth, ethnically
            diverse areas of the country. Through this initiative, NTID
            will identify those students demonstrating promise for success
            in career-focused degree-level programs and beyond, and provide
            consultation to others regarding postsecondary educational
            alternatives;
      --Expanding NTID's role as a National Resource Center of Excellence
            regarding the education of deaf and hard-of-hearing students in
            senior high school (grades 10, 11, and 12) and at the
            postsecondary level education. Components of this role as a
            National Resource Center of Excellence will include:
        --Center for Excellence in STEM Education.--NTID currently is
                working to develop an externally funded Center of
                Excellence on STEM Education for Deaf and Hard of Hearing
                Students. This is an example of making our expertise
                available nationally and enhancing deaf and hard-of-hearing
                students' access to STEM fields.
        --NTID Research Centers.--NTID will organize research resources
                into Research Centers focused on the following strategic
                areas of research: Teaching and Learning; Communication;
                Technology, Access, and Support Services; and Employment
                and Adaptability to Social Changes and the Global
                Workplace.
        --Outreach Programs Extending.--Outreach activities to junior and
                senior high school students who are deaf and hard-of-
                hearing, many of who represent AALANA populations, to
                expand their horizons regarding a college education. We
                also support other colleges and universities serving
                students who are deaf and hard-of-hearing, as well as
                postcollege adults who are deaf and hard-of-hearing.
      --Enhancing efforts to become a recognized national leader in the
            exploration, adaptation, testing, and implementation of new
            technologies to enhance access to, and support of, learning by
            deaf and hard-of-hearing individuals.

                                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. NTID also is expanding the number of its transfer
    associate degree programs, currently numbering seven, to better serve
    the higher achieving segment of our student population seeking
    bachelors and masters degrees in an increasingly demanding marketplace.
    These transfer programs provide seamless transition to baccalaureate
    studies in the other colleges of RIT. In support of those deaf and
    hard-of-hearing students enrolled in the other RIT colleges, NTID
    provides a range of access services (including interpreting, real-time
    speech-to-text captioning, and note-taking) as well as tutoring
    services. One of NTID's greatest strengths is our outstanding track
    record of assisting high-potential students to gain admission to, and
    graduate from, the other colleges of RIT at rates comparable to their
    hearing peers.
    Student Life
        Our activities foster student leadership and community service, and
    provide opportunities to explore a wide range of other educational
    interests. Emphasis is placed on coordination between academic faculty
    and student development professionals in supporting college success for
    students.

                                    SUMMARY

        It is extremely important that our funding be provided at the full
    level requested by the President as we continue our mission to prepare
    deaf and hard-of-hearing people to enter the workplace and society. We
    ask only that the funds provided by the President for Construction be
    moved into operations.
        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 SSI, SSDI, and public assistance 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 people who are deaf
    and hard-of-hearing, remains deserving of your support and confidence.
                                     ______

             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 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 at
    institutions of higher education, education and training for clean
    energy and ``green'' jobs, environmental education at the K-12 level,
    and national service programs that we believe are vital to NWF's
    mission to inspire Americans to protect wildlife for our children's
    future. The National Wildlife Federation 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 Aeronautics and Space
    Administration, National Oceanic and Atmospheric Administration, and
    U.S. Department of the Interior.

                                               SUMMARY OF RECOMMENDATIONS
                                                [In millions of dollars]
    ----------------------------------------------------------------------------------------------------------------
                                                                                        Fiscal year
                    Agency                                  Program                        2011         Fiscal year
                                                                                      recommendation    2010 level
    ----------------------------------------------------------------------------------------------------------------
    Education............................  University Sustainability Program........             $50         ( \1\ )
                                           Healthy High Performance Schools.........              25  ..............
    Labor................................  Green Jobs Act...........................             125             $50
    CNCS.................................  Clean Energy Service Corps...............             100  ..............
    ----------------------------------------------------------------------------------------------------------------
    \1\ See under Department of Education.

        Funding for these programs is supported broadly through the
    Campaign for Environmental Literacy's Green Education Budget and the
    conservation community's Green Budget documents.
    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 pass comprehensive climate change legislation this
    year, a priority that the National Wildlife Federation strongly
    supports. To be successful and remain competitive as a Nation in a new
    clean energy economy, we must have an environmentally literate and
    well-trained 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.
        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 through comprehensive climate change
    legislation. Unfortunately, some still mistakenly see environmental
    protection programs as a costly burden on prosperity. In fact, the
    challenge posed is an entrepreneur's dream. 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, in our Nation's K-12 schools,
    through conservation corps programs that educate and train at-risk
    youth for careers in clean energy, and through green workforce
    education and training programs at the Department of Labor.

                            DEPARTMENT OF EDUCATION

    University Sustainability Program
        The National Wildlife Federation supports funding the University
    Sustainability Program (USP) at $50 million in fiscal year 2011.
    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 the National Wildlife Federation 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 University Sustainability Program (USP)
    at the Department of Education as part U of the 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.
        In fiscal year 2010 Congress appropriated $28.8 million for the
    University Sustainability Program and five other programs as
    ``invitational priorities'' under the Fund for Improvement in
    Postsecondary Education. We recommend that in fiscal year 2011 Congress
    fund the University Sustainability Program as a standalone program at
    $50 million.
    Healthy High Performance Schools Program
        The National Wildlife Federation supports funding the Healthy High
    Performance Schools Program at $25 million in fiscal year 2011. 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. This
    program has yet to be funded by Congress. While it would seem to be a
    given that we are providing our children with a healthy learning
    environment, many of the Nation's 150,000 public school buildings fall
    far short of this standard. Research clearly shows that improving
    specific factors such as school indoor environmental quality improves
    attendance, academic performance, and productivity.
    Pre-K-12 Environmental Education--No Child Left Inside Act
        While not yet authorized, the National Wildlife Federation strongly
    supports authorization of and full funding at $100 million per year for
    the No Child Left Inside (NCLI) Act (H.R. 2054), which the support of
    more than 1,600 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 pre-K-12 education system. These
    State plans in NCLI support training and professional development
    opportunities for teachers and capacity building for environmental
    education at both the State and district level. In the past 12 years,
    an impressive base of research has been developed that demonstrates the
    positive effects that environmental and nature education programs have
    on improving academic performance and overall student learning. These
    data, collected from many peer-reviewed sources, include: improved
    statewide test results, higher scores in science and mathematics,
    higher student interest in science, greater real-world relevancy, fewer
    discipline problems in the classroom, and a more even playing field for
    students in under-resourced schools.
        The House passed a modified version of the bill in the 110th
    Congress by a bipartisan vote of 293-109. This strong support continues
    today with 90 current sponsors of H.R. 2054. Additionally, the
    Department of Education's A Blue Print for Reform: The Reauthorization
    of the Elementary and Secondary Education Act seeks to encourage
    schools to provide a well-rounded education through grants that support
    strengthening teaching and learning in environmental education. In
    fiscal year 2011, ``environmental education'' was also included in the
    President's budget request under a ``Well-Rounded Education.''
        The National Wildlife Federation also supports a priority for
    funding green career and technical education programs and initiatives
    at the Department of Education.

                              DEPARTMENT OF LABOR

        The National Wildlife Federation supports a priority for green jobs
    education and training at the Department of Labor through the Workforce
    Investment Act's Energy Efficiency and Renewable Energy Worker Training
    Program and the Community Based Job Training Program. NWF believes that
    community colleges are critical partners in training and educating the
    next generation of Americans for green jobs.
    Energy Efficiency and Renewable Energy Worker Training Program
        The National Wildlife Federation supports funding the Energy
    Efficiency and Renewable Energy Worker Training Program at $125 million
    in fiscal year 2011. NWF greatly appreciates this subcommittee's first-
    time investment in Green Jobs Education and Training in the recent
    American Recovery and Reinvestment Act and the $50 million provided in
    fiscal year 2010. This unprecedented investment will help jumpstart the
    education and training needed to prepare Americans for the clean energy
    economy. We hope that the Committee will continue to fund this program,
    authorized by the Green Jobs Act (GJA), title X of the Energy
    Independence and Security Act, at $125 million in fiscal year 2011. 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'' and
    responds to already existing skill shortages.

                 CORPORATION FOR NATIONAL AND COMMUNITY SERVICE

    Clean Energy Service Corps
        The National Wildlife Federation supports funding the Clean Energy
    Service Corps at $100 million in fiscal year 2011. 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.

                                   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. Thank you again for providing the National
    Wildlife Federation with the opportunity to provide testimony.
                                     ______

           Prepared Statement of The Ovarian Cancer National Alliance

        The Ovarian Cancer National Alliance (the Alliance) appreciates the
    opportunity to submit comments for the record regarding the Alliance's
    fiscal year 2011 funding recommendations. We believe these
    recommendations are critical to ensure advances to help reduce and
    prevent suffering from ovarian cancer. For 13 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 49 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 2009, 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 (FDA) 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 reasons, 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 2011.
        The Alliance also fully supports Congress in taking action on
    educating Americans about ovarian cancer through providing funding for
    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 2011.
        Further, the Alliance urges Congress to continue funding the
    Specialized Programs of Research Excellence (SPOREs), including the
    five 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 $5.795
    to the National Cancer Institute for fiscal year 2011.

                CENTERS FOR DISEASE CONTROL AND PREVENTION (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.
        The CDC's Ovarian Cancer Control conducts research about early
    detection, treatment and survivorship nationwide to increase
    understanding of ovarian cancer. Some ongoing research includes
    studying: the relationship between recorded symptoms, time to
    diagnosis, and ovarian cancer histology, the availability of
    gynecologic oncologists for ovarian cancer care, and frequency of
    symptoms in women aged 65 years and older with ovarian cancer as
    compared to a matched cohort of cancer-free women, among many other
    research projects.
    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.
        Thanks to funding under Johanna's Law, more women are learning how
    to identify the signs and symptoms of gynecologic. The CDC have
    developed and disseminated over 275,000 fact sheets on gynecologic
    cancers in English and Spanish, created a Web page dedicated to
    information about these diseases that receive more than 1,500 hits a
    day, and are producing public service announcements for television
    scheduled to air beginning in September 2010. We must ensure that
    lifesaving information about gynecologic cancers continues to reach
    women.
        With continued funding, the CDC will be able to continue to print
    and distribute brochures, maintain and update the Web resources,
    develop additional educational materials such as posters for physician
    offices, complete continuing education materials for healthcare
    providers, and reach out to women beyond the original 40-60 year-old
    initial target group.

                                      NCI

    Specialized Programs of Research Excellence (SPORE) in the National
            Institutes of Health
        The SPOREs were created by the NCI in 1992 to support
    translational, organ site-focused cancer research. The ovarian cancer
    SPOREs began in 1999. There are five currently funded Ovarian Cancer
    SPOREs located at the MD Anderson Cancer Center, the Fred Hutchinson
    Cancer Research Center, the Fox Chase Cancer Center, the Dana Farber/
    Harvard Cancer Center and the Mayo Clinic 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
        The 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, 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 2011 funding for the CDC's Ovarian Cancer
    Control Initiative and $10 million in fiscal year 2011 funding for
    Johanna's Law as well as your continued support of the SPORES program,
    an appropriation of $5.795 billion to NCI.
                                     ______

               Prepared Statement of the Oncology Nursing Society

        The Oncology Nursing Society (ONS) appreciates the opportunity to
    submit written comments for the record regarding fiscal year 2011
    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 1.48 million Americans will be diagnosed with
    cancer, and more than 562,340 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 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 2009. http://
    www.cancer.org/downloads/STT/500809web.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 2011 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 decline 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 greatly appreciates the increase in funding in fiscal year
    2010. This represents an investment in patient care. ONS joins our
    colleagues from all nursing sectors and specialties to request $267.3
    million, a 10 percent increase over last year's level, for the Health
    Resources and Services Administrations (HRSA) title VIII programs in
    fiscal year 2011. The title VIII programs received a substantial
    increase in fiscal year 2010. Funding for these programs increased from
    $171.03 million to $243.872 million, a 42.6 percent increase. In
    particular the Nursing Faculty Loan Program received a 117 percent
    increase and the Loan Repayment and Scholarship program received a 152
    percent increase. However, the Advanced Education Nursing, Nursing
    Workforce Diversity, Comprehensive Geriatric Education, and Nurse
    Education, Practice, and Retention programs, which help complement the
    Loan Repayment and Scholarship programs, have not kept pace with
    inflation since fiscal year 2005 and did not receive any increases last
    year. Therefore, ONS along with the Nursing Community is requesting
    that the 10 percent increase in funding be awarded to these four
    programs.
        With additional funding in fiscal year 2011, the HRSA Workforce
    Development Programs will have much-needed resources to address the
    multiple factors contributing to the nationwide nursing shortage.
    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
    $267.3 million in fiscal year 2011 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.
    The National Coalition for Cancer Research (NCCR), a nonprofit
    organization comprised of 23 national cancer organizations, and One
    Voice Against Cancer (OVAC), a collaboration of 39 national nonprofit
    organizations, are also advocating $267.3 million in fiscal year 2011
    for the Nurse Reinvestment Act. 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 13.5 percent
    increase ($35.210 billion) for NIH in fiscal year 2011. 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 $5.795 billion to the
    National Cancer Institute (NCI), as well as $240 million to the
    National Center for Minority Health and Health Disparities in fiscal
    year 2011 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 2011 allocation of $160 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 2011 funding levels for the
    following CDC programs:
      --$255 million for the National Breast and Cervical Cancer Early
            Detection Program;
      --$65 million for the National Cancer Registries Program;
      --$50 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 Gynecologic Cancer and Education and Awareness
            (Johanna's Law);
      --$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 groups, 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 2011 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, Chairman Harkin, 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 (Bureau ).
    Background on the Population Association of America/Association of
            Population Centers (PAA/APC) and Demographic Research
        The PAA is a scientific organization comprised of more than 3,000
    population research professionals, including demographers,
    sociologists, statisticians, and economists. The 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
    nationwide.
        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 on
    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 2011, HRS will
    collect biomarkers, enhancing its ability to track the onset and
    progression of diseases and conditions affecting the elderly.
        Currently, the NIA payline is 9 percent, and its operating line is
    flat. As research costs increase, NIA faces the prospect of funding
    fewer grants to sustain larger ones in its commitment base. With
    additional support in fiscal year 2011, the NIA BSR program could fully
    fund its large-scale projects, including the existing centers programs
    and ongoing surveys, without resorting to cost-cutting measures, such
    as cutting sample size, while continuing to support smaller
    investigator initiated projects. NIA could also sustain training and
    research opportunities for new investigators--especially those who
    received funding from the American Recovery and Reinvestment Act
    (ARRA).
    NICHD
        Since its establishment in 1968, the Eunice Kennedy Shriver 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 2011, NICHD could restore
    full funding to its large-scale surveys, which serve as a resource for
    researchers nationwide. Furthermore, the NICHD 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), the 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 recent steady funding increases, 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 were
    cut, while other surveys, most notably the National Hospital Discharge
    Survey, were not fielded. In 2009, NCHS 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.
    Fortunately, Congress and the new administration worked together to
    give NCHS adequate resources and avert implementation of these
    draconian measures. Nonetheless, the agency continues to operate in a
    precarious state.
        The administration recommends NCHS receive $161.9 million in fiscal
    year 2011. PAA and APC, as members of The Friends of NCHS, support the
    administration's request. The increased funding will be used to support
    a number of initiatives, including: (1) restore the National Health
    Interview Survey to 87,000; (2) fund 12 months of vital statistics data
    collection; and (3) implement re-engineered Web-based birth certificate
    data in 6 States and 4 territories; and (4) phase in electronic death
    certificate registration in States willing to enter a cost-sharing
    arrangement with the agency.
    BLS
        During these turbulent economic times, data produced by the 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 $645 million in fiscal year 2011. According to the agency, this
    funding level would enable BLS to improve the Consumer Expenditure
    Survey and reduce variance in the Consumer Price Index. Also, BLS could
    improve data used to measure occupational wage and employment growth
    and identify trends policymakers need to understand the turbulent labor
    market. Finally, the agency could support its work on developing an
    alternative poverty measure.
    Summary of Fiscal Year 2011 Recommendations
        As members of the Ad Hoc Group for Medical Research, PAA and APC
    are asking Congress to provide NIH with an appropriation of $35 billion
    in fiscal year 2011--$3 billion more than the administration's request.
    Although the administration's request for NIH reflects inflation, we
    feel NIH needs additional support to sustain the new research capacity
    created by ARRA.
        PAA and APC, as members of the Friends of NCHS, ask that NCHS
    receive $161.9 million in fiscal year 2011, 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, $645
    million, for the BLS, in fiscal year 2011.
        Thank you for considering our requests and for supporting Federal
    programs that benefit the population sciences.
                                     ______

      Prepared Statement of the Physician Assistant Education Association

        On behalf of its membership, the 149 accredited physician assistant
    (PA) education programs in the United States, the Physician Assistant
    Education Association (PAEA) is pleased to submit these comments on the
    fiscal year 2011 appropriations for PA education programs that are
    authorized through title VII of the Public Health Service Act.
        PAEA is a member of the Health Professions and Nursing Education
    Coalition (HPNEC) and we support the HPNEC recommendation for funding
    of at least $600 million in fiscal year 2011 for the health professions
    education programs authorized under title VII and VIII of the Public
    Health Service Act and administered through the Health Resources and
    Services Administration (HRSA).
        PAEA is grateful to the subcommittee for the recent funding
    increases for Title VII Health Professions programs in the Consolidated
    Appropriations Act, 2010 (Public Law 111-117) and for your support of
    Title VII health professions programs.
    Need for Increased Federal Funding
        Faculty development is one of the profession's critical needs. In
    order to attract the best qualified to teaching, PA education programs
    must have the resources to train faculty in academic skills, such as
    curriculum development, teaching methods, and laboratory instruction.
    The challenges of teaching are broad and varied and include
    understanding different pedagogical theories, writing instructional
    objectives, and learning and applying educational technology. Most
    educators come from clinical practice and these skills are essential to
    transitioning to teaching. Educators are a critical element of meeting
    the Nation's demand for an increased supply of primary care clinicians.
        Generalist training, workforce diversity, and practice in
    underserved areas are key priorities identified by HRSA. It is
    increasingly important that the health workforce better represents
    America's changing demographics, as well as addresses the issues of
    disparities in healthcare. PA programs have been successful in
    attracting students from underrepresented minority groups and
    disadvantaged backgrounds. Studies have found that health professionals
    from underserved areas are 3 to 5 times more likely to return to
    underserved areas to provide care.
    Physician Assistant Practice
        Physician assistants (PAs) are licensed health professionals who
    practice medicine as members of a team with their supervising
    physicians. PAs exercise autonomy in medical decisionmaking and provide
    a broad range of medical and therapeutic services to diverse
    populations in rural and urban settings. In all 50 States, PAs carry
    out physician-delegated duties that are allowed by law and within the
    physician's scope of practice and the PA's training and experience.
    Additionally, PAs are delegated prescriptive privileges by their
    physician supervisors in all 50 States, the District of Columbia, and
    Guam. This allows PAs to practice in rural, medically underserved areas
    where they are often the only full-time medical provider.
    Physician Assistant Education
        There are currently 149 accredited PA education programs in the
    United States, which together graduate nearly 6,000 PA students each
    year. PAs are educated as generalists in medicine; their flexibility
    allows them to practice in more than 60 medical and surgical
    specialties. More than one-third of PA program graduates practice in
    primary care.
        The average PA education program is 27 months in length. Typically,
    1 year is devoted to classroom study and approximately 15 months is
    devoted to clinical rotations. The typical curriculum includes 400
    hours of basic sciences and nearly 600 hours of clinical medicine.
        The profession is expected to continue to grow as a result of the
    projected shortage of physicians and other healthcare professionals,
    the growing demand for professionals from an aging population, and the
    continuing strong PA applicant pool, which has grown by more than 10
    percent each year since the year 2000. The Bureau of Labor Statistics
    projects a 39 percent increase in the number of PA jobs between 2008
    and 2018. With its relatively short initial training time and the
    flexibility of generalist-trained PAs, the PA profession is well-
    positioned to help fill projected shortages in the numbers of
    healthcare professionals.
        Currently there are almost 20 new PA programs in the accreditation
    pipeline. The continued growth of the profession heightens the need for
    additional resources. Additional resources will help meet the
    challenges of recruiting qualified faculty, shortages of preceptors and
    clinical sites, and the need to continue our work to increase the
    diversity of faculty and program applicants.
    Title VII Funding
        Title VII funding is the only opportunity for PA programs to apply
    for Federal funding and plays a crucial role in developing and
    supporting PA education programs.
        Title VII funding fills a critical need for curriculum development
    and faculty development. Funding enhances clinical training and
    education, assists PA programs with recruiting applicants from minority
    and disadvantaged backgrounds, and funds innovative programs that focus
    on educating a culturally competent workforce. Title VII funding
    increases the likelihood that PA students will practice in medically
    underserved communities with health professional shortages. The absence
    of this funding would result in the loss of care to patients in
    underserved areas.
        Title VII support for PA programs has been strengthened with the
    enactment of the Patient Protection and Affordable Health Care Act
    (Public Law 111-148), which provides a 15 percent carve out in the
    appropriations process for PA programs. This funding will enhance
    capabilities to train a growing PA workforce and is likely to increase
    the applicant pool for faculty positions as a result of PA programs now
    being eligible for faculty loan repayment. Huge loan burdens serve as
    barriers for PAs' entry into academia.
        Here we provide several examples of how PA programs have used Title
    VII funds to creatively expand care to underserved areas and
    populations, as well as to develop a diverse PA workforce.
      --One Texas program has used its PA training grant to support the
            program at a distant site in an underserved area. This grant
            provides assistance to the program for recruiting, educating,
            and training PA students in the largely Hispanic South Texas
            and mid-Texas/Mexico border areas and supports new faculty
            development.
      --A Utah program has used its PA training grant to promote
            interprofessional teams--an area of strong emphasis in the
            Patient Protection and Affordable Care Act--by creating a model
            geriatric curriculum that includes didactic and clinical
            education. The grant has also allowed the program to optimize
            its relationship with three service-learning partners and
            develop new partnerships with three service-learning sites.
      --An Alabama program used its PA training grant to update and expand
            the current health behavior educational curriculum and HIV/STD
            training. They were also able to include PA students from other
            programs who were interested in rural, primary care medicine
            for a 4-week comprehensive educational program in HIV disease
            diagnosis and management.
      --A South Carolina program has developed a model program that offers
            a 2-year academic fellowship for recent PA graduates with at
            least 1 year of clinical experience. To further enhance an
            evidence-based approach to education and practice, two specific
            evidence-based practice projects were embedded in the
            fellowship experience. Fellows direct and evaluate PA students'
            involvement in the ``Towards No Tobacco'' curriculum, aimed at
            fifth graders, and the PDA Patient Data experience, aimed at
            assessing healthcare services.
    Recommendations on Fiscal Year 2011 Funding
        The Physician Assistant Education Association requests the
    Appropriations Committee to support funding for title VII and VIII
    health professions programs at a minimum of $600 million for fiscal
    year 2011. This level of funding is crucial to support the Nation's
    demand for primary care practitioners, particularly those who will
    practice in medically underserved areas and serve vulnerable
    populations. Additionally we encourage support for the new programs and
    responsibilities contained in the Patient Protection and Affordable
    Care Act (Public Law 111-148), including a minimum of $10 million to
    support PA education programs. We thank the members of the subcommittee
    for their continued support of the health professions and look forward
    to your continued support of solutions to the Nation's health workforce
    shortage. We appreciate the opportunity to present the Physician
    Assistant Education Association's fiscal year 2011 funding
    recommendation.
                                     ______

      Prepared Statement of the Patient Alliance for Neuroendocrineimmune
                Disorders Organization for Research and Advocacy

        Dear Chairman of the subcommittee on Labor, Health and Human
    Services, and Education, and Related Agencies: On behalf of our
    organization I want to share with you a matter of great importance to
    our patient advocacy organization. It is related to the CFS Advisory
    Committee (CFSAC), a congressional committee overseen by the Department
    of Health and Human Services established to provide science-based
    advice and recommendations to the Secretary of Health and Human
    Services and the Assistant Secretary for Health on a broad range of
    issues and topics pertaining to chronic fatigue syndrome (CFS). It has
    been at least 6 years since our organization has attended and provided
    input during CFSAC meeting and yet not one single crucial
    recommendation has been implemented or enacted. Currently the CFSAC is
    due to expire on September 5, 2010.
        We need to call you attention why is so important that this
    appropriation committee provide funding for research, patient care,
    physician education, and clinical trial within a center of excellence
    format. The CFSAC has consistently year after year as far back as
    September 2004 recommended the following:
        In September 2004--Recommendation 1.--We would urge the DHHS to
    direct the NIH to establish five Centers of Excellence within the
    United States that would effectively utilize state of the art knowledge
    concerning the diagnosis, clinical management, treatment and clinical
    research of persons with CFS. These Centers should be modeled after the
    existing Centers of Excellence program, with funding in the range of
    $1.5 million per center per year for 5 years.
        In August 2005--Recommendation 1.--We would urge the DHHS to direct
    the NIH to establish five Centers of Excellence within the United
    States that would effectively utilize state-of-the-art knowledge
    concerning the diagnosis, clinical management, treatment, and clinical
    research of persons with CFS. These Centers should be modeled after the
    existing Centers of Excellence program, with funding in the range of
    $1.5 million per center per year for 5 years.
        In November 20-21, 2006.--The Committee skipped recommending again
    because it was told that it needed to wait till the Secretary of Health
    could reply on the earlier recommendations therefore CFSA then provided
    recommendation 3--The committee recommends that CFS be included in the
    Roadmap Initiative of the NIH.
        In May 16-17, 2007--Recommendation 1.--There have been basic
    science advances which should be leading to new treatment strategies,
    yet progress in translating these advances into effective treatments
    has been slow. This is in large part due to a complete lack of clinical
    care centers and research centers. Investigators are frustrated by a
    lack of access to representative patient populations, and patients are
    frustrated by a lack of accessible expert clinical treatment centers.
    Funding mechanisms to develop new centers for either clinical care or
    centers for research are shrinking, but the needs of this underserved
    very ill patient population are unmet and growing.
        Therefore, the CFSAC recommends that the Secretary use the
    resources and talent of the agencies that make up the HHS to find ways
    to meet these needs. One starting point is our request that the HHS
    establish 5 regional clinical care, research, and education centers,
    centers which will provide care to this critically underserved
    population, educate providers, outreach to the community, and provide
    effective basic science, translational and clinical research on CFS.
    The advisory committee understands that fiscal exigencies have to date
    prevented the formation of these previously recommended centers, but it
    is our hope the Secretary will use the full weight of his office to
    effectively fund this program through existing funding mechanisms that
    might be available or new programs.''
        In November 28-29, 2007.--CFSAC voted unanimously to send the
    following recommendations to the Assistant Secretary for Health for
    transmittal to the Secretary:
      --It is recommended that a representative of AHRQ be added as an ex
            officio member to CFSAC effective immediately, but at least in
            advance of the next CFSAC meeting. The next CFSAC meeting is
            scheduled to be held in May 2008.
      --It is recommended that the CDC effort on CFS be restructured to
            reflect a broader expertise on the multifaceted capabilities
            required to execute a comprehensive program that incorporates
            the following elements:
        --an extramural effort directed by the Office of the Director;
        --sufficient funds for a program for which the authority and
                accountability is housed at the level of a coordinating
                center director;
        --a lab-based component that maintains the current search for
                biomarkers and pathophysiology;
        --the recommendations of the external CDC Blue Ribbon panel,
                including developing, analyzing, and evaluating new
                interventions and continuing support for longitudinal
                studies; and
        --an expanded patient, healthcare provider, and family caregiver
                education effort that is managed by staff with appropriate
                expertise in clinical and public education strategies.
        In May 5-6, 2008.--The committee unanimously recommended 4 items.
    For the purpose of my testimony I quote: ``CFSAC recommends to the
    Secretary of Health and Human Services that the Administrator of HRSA
    communicate with each Area Health Education Center (AHEC) regarding the
    critical need for provider education of CFS. HRSA has the potential to
    disseminate information on CFS to a wide range of providers,
    communities and educational institutions. HRSA should inform these
    groups that persons with CFS represent an underserved population and
    that there is a dramatic need for healthcare practitioners who can
    provide medical services to CFS patients. HRSA should further inform
    these groups that the CDC offers a web based CME program on CFS at
    www.cdc.gov/cfs; and encourage AHEC providers to participate in this
    CME program. Additionally, HRSA should alert AHECs of the availability
    of a CDC CFS provider toolkit.''
        In October 28-29, 2008.--Several recommendations were made. For the
    purpose of our testimony we quote:
      --``It is recommended that DHHS solicit the Department of Education's
            cooperation on issues relating to pediatric CFS.
      --``It is recommended that the Transition report to the new
            Administration and Secretary include the background of the
            CFSAC and CFS and a list of the recommendations that have been
            developed by this Committee over the past two chartered
            periods, with any action taken on each point.
      --``CFSAC endorses the planned State of the Knowledge Conference to
            be developed by the NIH.
      --``CFSAC recognizes that much can be done to ensure that every child
            with CFS has the best possible access to support and treatment
            and asks that the Secretary facilitate a taskforce or working
            group to establish an ongoing interagency and interdepartmental
            effort to coordinate school, family, financial, and healthcare
            support for children and young adults with CFS.''
        In October 29-30, 2009--Recommendation 1.--Establish Regional
    Centers funded by DHHS for clinical care, research, and education on
    CFS. (Resubmitted from May 2009)
        As you can see, year after year, the same recommendation is being
    made, and yet there has not been any progress for the past 6 years in
    the most important recommendation from the CFSAC to the Secretary of
    Health regarding chronic fatigue syndrome. Therefore we urge you--our
    congressional leadership--to ensure funding for the
    Neuroendocrineimmune (NEI) CenterTM and to the Whittemore
    Peterson Institute. Please allocate funding for scientific research,
    clinical trials, patient registry, physician education, public
    education and social services to an estimated 20 million Americans
    stricken with neuroendocrineimmune disorders such as chronic fatigue
    syndrome (CFS) and related illnesses. Throughout the United States, day
    after day we witness great suffering being inflicted on individuals,
    children, teenagers, adults and the elderly. We witness children being
    taken from their families simply because they ``have failed to find a
    primary physician to treat their child'' (Baldwin Family vs. DSS
    Buncombe County, North Carolina). Too much suffering because it seems
    that no one in our government cares to take courageous step and stand
    up for individuals with CFS.
        We urge you to provide funding to The NEI CenterTM, a
    patient-driven community initiative in the State of New Jersey
    (hopefully in Florida as well), which will address all of the issues
    mentioned on the CFSAC recommendation in addition to addressing
    patient's quality of life issues. The cornerstone of the NEI
    CenterTM (www.neicenter.com) is that discoveries and
    advances made in any one of the neuroendocrineimmune illnesses: chronic
    fatigue syndrome (CFS), myalgic encephalomyelitis or encephalopathy
    (ME), fibromyalgia (FM), Gulf War syndrome/illness (GWS/GWI), multiple
    chemical sensitivity (MCS), environmental illness (EI), chronic or
    persistent Lyme disease (CLD-PLD), Alzheimer's Disease (AD), and
    autism, will be applicable and beneficial to other neuroendocrineimmune
    illnesses, thereby bringing us closer to a cure.
        I ask you why hasn't this crucial issue be addressed promptly? Why
    has our government failed to address such injustice? I urge you to
    stand by the side of millions of Americans who presently do not have a
    voice. Their future depends on your vision. Help us to restore their
    health and their hopes. Please provide funding to the NEI
    CenterTM and or similar efforts in the United States. This
    committee has the power. You can do it. And as one of the many
    individuals stricken with CFS, I thank you for this opportunity to
    share the plight of so many. We need a hero, and you have the
    opportunity to demonstrate vision, courage and foresight by allocating
    funding for future centers of excellence for CFS and other
    neuroendocrineimmune disorders. Thank you.
                                     ______

     Prepared Statement of the Program for Appropriate Technology in Health

        Program for Appropriate Technology in Health (PATH) appreciates the
    opportunity to submit written testimony regarding fiscal year 2011
    funding for global health research and development to the Senate Labor,
    Health and Human Services, and Education, and Related Agencies
    Appropriations Subcommittee. PATH is an international nonprofit
    organization that creates sustainable, culturally relevant solutions,
    enabling 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.
        The ongoing 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 impoverished countries, 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.
        Such discoveries will require increased funding for global health
    research and development (R&D). Although the U.S. Government remains
    one of the most important investors in the development of new
    technologies, the need overshadows the contribution.
        When looking at U.S. spending on R&D writ large over the last four
    decades, Federal spending on all R&D, expressed as a percentage of
    gross domestic product (GDP), has declined by more than 60 percent:
    from just under 2 percent of GDP in 1965 to less than 1 percent in
    2007.\1\ During a speech delivered in early 2009, President Obama
    expressed a desire to reverse that trend by requesting a Federal R&D
    budget of $147.6 billion for fiscal year 2010 and by setting a goal of
    increasing national investment in R&D to more than 3 percent of GDP.\2\
    Seizing upon this momentum, in fiscal year 2010 Congress appropriated
    $150.4 billion for national research and development--a 2.4 percent
    increase from 2009 funding. While global health R&D is just one
    component of the overall national R&D budget, PATH thanks you for this
    allocation and believes that this is a significant step towards
    achieving our country's global health goals.
    ---------------------------------------------------------------------------
        \1\ National Science Foundation. Gross domestic product and
    research and development (federally funded, non-Federal, and total):
    1953-2007. Arlington, VA: NSF; 2008. Available at: http://www.nsf.gov/
    statistics/nsf08318/pdf/tab13.pdf.
        \2\ Speech to NAS, April 27, 2009. http://www.whitehouse.gov/
    the_press_office/Remarks-by-the-President-at-the-National-Academy-of-
    Sciences-Annual-Meeting/.
    ---------------------------------------------------------------------------
        Robust and sustained R&D funding is crucial to continued global
    health advancements. Developing a single drug--from basic discovery to
    clinical testing to product licensure--can cost as much as $800 million
    and may take up to a decade.\3\ Developing more complex products may
    take even longer and be even more expensive--as much as $1.2
    billion.\4\ R&D costs rise as products advance through clinical
    testing. In order to test whether a vaccine is safe and effective in
    humans, for example, researchers require thousands of volunteers and
    hundreds of health workers. As a result, late-stage trials are
    typically more expensive to complete than earlier trials.
    ---------------------------------------------------------------------------
        \3\ Conference Report to Accompany H.R. 2997. September 30, 2009.
    http://www.rules.house.gov/111/LegText/111_agcr_txt.pdf, p. 84.
        \4\ Tufts Center for the Study of Drug Development. Research
    Milestones. June 19, 2009. http://csdd.tufts.edu/Research/
    Milestones.asp http://www.accessdata.fda.gov/scripts/opdlisting/oopd/
    index.cfm.
    ---------------------------------------------------------------------------
        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. Several
    programs funded in the Labor, Health and Human Services, and Education,
    and Related Agencies 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 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 from the widely dispersed populations they
    serve. Specialized equipment, personnel, and safe waste-disposal
    systems are often not available. Without diagnostic testing, healthcare
    professionals have to rely solely on symptoms to diagnose and treat
    illness--an imperfect method given the similarity of symptoms among
    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.
        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 such 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.
        Without sufficient funding for NIH and CDC, much of the cutting-
    edge R&D 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, neglected diseases such as Chagas disease, and other
    conditions whose heaviest burden falls on the developing world do not
    have a significant commercial market to incentivize research and
    development. Without investment by the U.S. Government, efforts to
    develop lower cost, easy to use, and appropriate 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.
        One promising area of innovation is nucleic acid (NA) amplification
    and detection, which is the most accurate way to diagnose many diseases
    that affect global health. Low-cost, highly accurate tests of this type
    are usually not available in low-resource settings. The small numbers
    of centralized laboratories that exist in developing countries tend to
    be in urban areas and cater primarily to the affluent. In contrast,
    rural healthcare facilities commonly have only basic equipment, and
    health workers have limited training and little ability to maintain
    equipment and handle reagents. Unreliable electric power to run the
    tests is also a major obstacle.
        Research conducted by PATH with support from NIH and CDC has
    pointed to the technical feasibility of a new, low-cost, disposable
    diagnostic platform for NA tests that can be used for detection of a
    wide variety of infectious diseases, including infant HIV and
    tuberculosis (TB). Other combinations of diagnostic technologies are
    also being explored with support from USAID and private funders. Small,
    portable, low-cost, instrument-free NA amplification tests that do not
    require electricity would have a vital impact on the ability of health
    workers and clinicians in developing countries to correctly and quickly
    diagnose disease. Patients who come from long distances and often
    cannot wait a few days to receive test results would be able to receive
    a diagnosis and treatment regimen on site at the point of care. Such
    tests could potentially replace the need for multi-million dollar
    central laboratory facilities.
        Another area where agencies funded by this subcommittee are making
    a significant contribution to global health is 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 these deaths 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 R&D for malaria vaccines,
    in partnership with the PATH Malaria Vaccine Initiative (MVI). NIH
    supports much of the basic research that underpins malaria drug and
    vaccine development efforts; the National Institute of Allergy and
    Infectious Diseases, an institute within NIH, is a particularly central
    player in malaria vaccine development efforts. CDC performs
    epidemiological research and international disease surveillance of
    malaria, providing critical data on the prevalence and spread of each
    of the four strains of the malaria parasite and the effectiveness of
    existing interventions.
        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. Due in part
    to investments by the U.S. Government, there is one malaria vaccine
    candidate that, if proven, is just 5 years or so from introduction. In
    May 2009, RTS,S--developed by GlaxoSmithKline Biologicals--entered a
    large-scale phase 3 clinical trial, which is typically one of the final
    steps before licensure. The trial is being conducted at 11 African
    study centers in seven countries. Two of the centers, both in Kenya,
    are partnered with U.S. Government agencies, including the CDC and the
    Walter Reed Army Institute of Research. Results from one phase 2
    clinical study show that RTS,S reduced the risk of clinical malaria by
    53 percent in children aged 5 to 17 months. Although this is exciting
    news, it represents not an end, but a beginning for malaria vaccine
    development. In order to develop more effective vaccines towards the
    ultimate goal of eradication, increased investment in research and
    development at NIH and CDC must continue.
        The U.S. Department of Health and Human Services is also using its
    investments in science and technology to facilitate pandemic influenza
    preparedness. With support from the Biomedical Advanced Research and
    Development Authority (BARDA), PATH is supporting the enhancement of
    sustainable influenza vaccine production capacity in Vietnam as part of
    global preparedness efforts for a future pandemic. We are collaborating
    with various partners in Vietnam, including the Government of Vietnam
    and vaccine manufacturers, to assist in the production and clinical
    evaluation of affordable, high-quality influenza vaccines. The project
    builds upon support that BARDA is currently providing to the World
    Health Organization to assist Vietnam in preparing for eventual
    licensure and commercial-scale manufacturing of influenza vaccines and
    is an important step toward increasing local and regional vaccines
    supplies. This is part of a long-term strategy of international
    capacity building. As the H1N1 outbreak demonstrated, the emergence of
    a pandemic strain is unpredictable and the public health response needs
    are to rapidly create, manufacture, and distribute novel vaccines.
    Because of global travel and our interconnected world, international
    cooperation on influenza preparedness has direct relevance for health
    here in the United States.
        Continued progress in our Nation's effort to improve global health
    requires the development of new tools and technologies, which are
    heavily reliant on research performed and supported by NIH, CDC, and
    BARDA. For these reasons, we respectfully request robust funding for
    NIH, CDC, and BARDA to allow the agencies to maximize global health
    efforts, which each has stated as a priority for fiscal year 2011.
    Funding for these agencies is critical to moving forward research on
    HIV/AIDS, TB, malaria, and other diseases which disproportionately
    impact low-income countries. We support the President's budget request
    as the minimum amount needed for the Labor, Health and Human Services,
    and Education, and Related Agencies account for fiscal year 2011.
        We very much appreciate the subcommittee's consideration of our
    views, and we stand ready to work with subcommittee members and staff
    to ensure continued support for these important issues which are
    essential to achieving our country's global health goals.
                                     ______

                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 2011
    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 2011 to help promote eye health and prevent eye disease and
    vision loss:
      --$5 million for the Vision Health Initiative at the Centers for
            Disease Control and Prevention (CDC);
      --$1.2 million in fiscal year 2011 to support the Maternal and Child
            Health Bureau's (MCHB) National Universal Vision Screening for
            Young Children's Coordinating Center (Center);
      --$730 million in fiscal year 2011 for the title V Maternal and Child
            Health (MCH) Services Block Grant; and
      --Increased fiscal year 2011 funding 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 meaningful Federal
    funding for: programs that help promote eye health and prevent eye
    disease, vision loss, and blindness; needed services and increased
    access to vision screening; and vision and eye disease research. We
    thank the subcommittee for its consideration of our specific fiscal
    year 2011 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 ten
    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 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.
    ---------------------------------------------------------------------------
      --Supporting the eye evaluation component of the National Health and
            Nutrition Examination Survey (NHANES) that provides current,
            nationally representative data and helps assess progress for
            vision objectives contained within Healthy People 2010 and the
            future efforts for Healthy People 2020.
      --Utilizing 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.
      --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.
        --Under the leadership of researchers at Johns Hopkins University
                investigating the best methods for identifying patients who
                need eye care services and providing linkages to follow-up
                care within community health centers.
        --In coordination with researchers at Duke University evaluation of
                strategies in primary care and pediatric settings to
                improve the detection of childhood vision conditions and
                diseases.
      --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 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.
        In fiscal year 2010, PBA requested $4.5 million to sustain and
    expand the Vision Health Initiative. In the final fiscal year 2010
    Consolidated Appropriations Act, Congress allocated $3.229 million a
    $7,000 increase from fiscal year 2009. 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 respectfully requests the subcommittee provide a
    $5 million allocation for the Vision Health Initiative. This level of
    investment will help the CDC sustain and expand its efforts to address
    the growing public health threat of preventable vision loss among at-
    risk and underserved populations. Additional fiscal year 2011 resources
    will support: strengthen State-based public health efforts to address
    vision and eye health; development of additional evidence-based public
    health interventions that improve eye health among the Nation's most
    at-risk and underserved; and expand initiatives to address the growing
    problem of diabetes among children and the associated impacts of
    diabetic retinopathy, which can develop later in life.
    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.
    ---------------------------------------------------------------------------
        In 2009, the Maternal and Child Health Bureau created the National
    Universal Vision Screening for Young Children Coordinating Center, a
    national vision health collaborative effort aimed at developing the
    public health infrastructure necessary to promote eye health and ensure
    access to a continuum of eye care for young children. PBA is requesting
    $1.2 million in fiscal year 2011 for the National Universal Vision
    Screening for Young Children Coordinating Center.
        With this level of funding, the Center, will continue to:
      --Partner with public and private entities--including State title V
            programs for Children with Special Health Care Needs,
            pediatricians and primary care providers, families and parent
            organizations, professional societies and associations, Family-
            to-Family Health Information Centers, and State and community
            agencies such as Healthy Start, Head Start, and elementary
            schools--to expand the cadre of key stakeholders interested in
            promoting young children's vision health and improving early
            identification of vision problems in young children.
      --Develop and implement a statewide strategy to achieve universal
            screening of children by age 4.
      --Determine a mechanism for uniform collection and reporting of
            children's vision care and eye health data.
        With fiscal year 2011 funding, the Center also will be able to:
      --Broaden partnerships and expand coordination between the Center,
            the State agencies that administer the title V Maternal and
            Child Health Block Grant, and other State public health
            entities to improve the early identification of vision problems
            in children.
      --Support a consensus conference involving MCHB, CDC, the Agency for
            Healthcare Research and Quality, NEI, and the Office of Head
            Start to establish national standards for vision screening in
            young children.
        In addition, States need increased resources to sustain and expand
    the provision of critical healthcare services to millions of pregnant
    women, infants, and children, including those with vision and eye care
    needs. Beyond direct services, the Maternal and Child Health (MCH)
    Services Block Grant supports vital public health services and systems
    that promote optimal health and help prevent disease. Therefore,
    Prevent Blindness America supports appropriating $730 million in fiscal
    year 2011 for the title V MCH Services Block Grant.
    Advance and Expand Vision Research Opportunities
        PBA calls upon the subcommittee to increase its support 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. Research
    is critical to ensure that new treatments and interventions are develop
    to help reduce and eliminate vision problems and potentially blinding
    eye diseases facing consumers across the country. In 2009, Congress
    commended the NEI's leadership in basic and translational research
    through H. Res. 366 and S. Res. 209, which recognized NEI's 40 years as
    the National Institutes of Health Institute that leads the Nation's
    commitment to save and restore vision. The resolutions also designated
    2010-2020 as the Decade of Vision in recognition of the increasing
    health and economic burden of eye disease, mainly as a result of an
    aging population.
        The NEI will be able to continue to grow its efforts to:
      --Expand capacity for research, as demonstrated by the significant
            number of high-quality grant applications submitted in response
            to ARRA opportunities.
      --Address unmet need, especially for programs of special promise that
            could reap substantial downstream benefits, as identified by
            new NIH Director Dr. Francis Collins.
      --Fund research to reduce healthcare costs, increase productivity,
            and ensure the continued global competitiveness of the United
            States.
        By increasing funding for the NEI at the NIH, essential 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, treatment efforts, and health information
    dissemination will be bolstered.
    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 2011
    funding for the CDC's Vision Health Initiative, the Maternal and Child
    Health Bureau's National Universal Vision Screening for Young Children
    Coordinating Center and title V MCH Block Grants and the 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. 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 the Pancreatic Cancer Action Network

        Mr. Chairman and members of the subcommittee: First and foremost, I
    want to thank you for your leadership and support for medical research
    carried out under the auspices of the National Institutes of Health
    (NIH). Your continuing support recognizes that the basic resource of
    this country is its people, and the Nation's strength can be no greater
    than the health of its citizenry.
        On behalf of the patients, families and scientists who make up the
    Pancreatic Cancer Action Network, I especially thank you for helping to
    shine a spotlight on the fourth leading cause of cancer death in the
    United States and one of the most lethal forms of cancer: pancreatic
    cancer. Your vigilance and encouragement is helping to correct that
    situation. Unfortunately, of the more than 42,000 diagnosed with
    pancreatic cancer last year, statistically, 76 percent died within 12
    months of their diagnosis and 95 percent will die within 5 years. We
    therefore still have a long way to go before the diagnosis does not
    nearly guarantee a death sentence. And we have a long way to go before
    the only major cancer with a 5-year survival rate still in the single
    digits enjoys the progress made against so many other forms of cancer.
        Two years ago some of you and your colleagues met with Dr. Randy
    Pausch, whose book, The Last Lecture, inspired millions of us to live
    our dreams. He inspired us even though he was facing his toughest life
    challenge; he was battling pancreatic cancer.
        Dr. Pausch's last appearance on Capitol Hill was in March 2008. He
    died 4 months later. His message was that we must change the research
    paradigm at NIH by providing more funding for the hardest research
    problems like pancreatic cancer because if we tackle the hardest
    problems, it will help us solve the easier problems.
        Since Dr. Pausch's death there has been increased publicity of this
    deadly disease with the subsequent diagnosis and death of actor Patrick
    Swayze, and the diagnosis of U.S. Supreme Court Justice Ruth Bader
    Ginsberg. Despite this publicity, the cold, hard fact remains that the
    number of new cases diagnosed and the number of deaths caused by
    pancreatic cancer are increasing. In fact, according to some experts,
    the number of new pancreatic cancer cases was projected to rise by 12
    percent in 2009, and to grow by 55 percent by the year 2030. These are
    startling numbers. We must take action now to not only change the
    current statistics, but to ensure that we have the tools for the
    future.
        But what patients, families, and advocates find most troubling is
    that while remarkable progress has been made against so many other
    forms of cancer, the progress we have made to detect or treat
    pancreatic cancer has changed little over the past 40 years:
      --There is no early detection for pancreatic cancer and many of the
            risk factors are benign. As a result, the disease is usually
            diagnosed in its late stages, often after it has metastasized
            to other organs.
      --There are no effective treatment options, except for a surgical
            procedure called the Whipple that only approximately 15 percent
            of all pancreatic cancer patients are eligible for and 80
            percent of patients who have the surgery have a recurrence and
            die within 5 years.
        So, why has progress in pancreatic cancer been so slow in coming?
    The answer is two-fold. The pancreas is complex and, because of its
    location, a difficult organ to study. But frankly, the real obstacle is
    the failure to make this a priority. Despite the fact that pancreatic
    cancer is the fourth-leading cause of cancer death in the United
    States, historically less than 2 percent of the National Cancer
    Institute's (NCI's) budget is devoted to research in this field. I have
    included for the record a chart of NCI funding for the top five cancer
    killers--which includes pancreatic cancer--and their respective
    survival rates. This chart demonstrates in very dramatic fashion that
    there is a clear correlation between low investment in research and
    poor survival rates. When an investment has been made, the 5-year
    survival rates reflect those efforts.
        In the absence of a concerted, well-focused scientific agenda,
    promising research applications go unfunded; opportunities to explore
    early screening techniques and more effective therapeutic agents are
    forgone; and investigators become discouraged and move to other fields
    of study.
    Recommendations
        How can the problem be corrected? Yes, funding for the NCI must be
    increased. In that regard, we join with our partners in the One Voice
    Against Cancer Coalition to ask that you provide $5.79 billion in
    funding for the NCI in fiscal year 2011--an increase of $691 million
    over the fiscal year 2010 appropriation.
        But steps must also be taken to mount a sustainable research effort
    against pancreatic cancer. Far more resources--money which will attract
    more scientists--must be brought to bear in order to find early
    detection tools and more effective treatments. To those ends, we
    strongly recommend that:
      --a pancreatic cancer research grant program be established, like the
            program outlined in the H.R. 745 The Pancreatic Cancer Research
            and Education Act, to support prioritized research projects
            focused on basic research, finding more precise diagnostic and
            early detection tools and innovative clinical trials on
            promising therapeutic agents;
      --a policy of ``exceptions'' funding for grant applications whose
            primary focus is on pancreatic cancer needs to be re-instituted
            at the NCI; and
      --there must be more pancreatic cancer experts included on scientific
            review panels.
        Though the pool of NCI-funded researchers investigating pancreatic
    cancer has gradually expanded in recent years, it still remains
    disproportionately miniscule when compared to the number of researchers
    in the other leading cancer fields. The recommendations I have outlined
    will help remedy that problem. They will also challenge the research
    community to rely less on ``safe bets'' and tackle difficult, high-risk
    problems, such as pancreatic cancer.
        Thank you for your time and consideration.

                                     ______

            Prepared Statement of the Pew Children's Dental Campaign

        The Pew Children's Dental Campaign, a campaign of the Pew Center on
    the States, would like to thank the Subcommittee Chairman for allowing
    the submission of this testimony in support of fiscal year 2011
    appropriations for oral health programs.
        The Pew Campaign works primarily at the State level to ensure that
    more children receive dental care and benefit from policies proven to
    prevent tooth decay. We are also mounting a national campaign to raise
    awareness of the problem, recruit influential leaders to call for
    change, and showcase states that have made progress and can serve as
    models for pragmatic, cost-effective reform.
        The Cost of Delay, recently released by The Pew Center on the
    States, found that 10 years after the 2000 report by the U.S. Surgeon
    General called dental disease a ``silent epidemic,'' too little has
    changed. The report finds that two-thirds of the States are failing to
    ensure that disadvantaged children get the dental healthcare they need.
    The good news is that this problem can be solved. At a time when State
    budgets are strapped, children's dental health presents a rare
    opportunity for Federal policy makers to make meaningful investments
    without breaking the bank-while delivering a strong return to
    taxpayers.
        The consequences of poor dental health among children are far
    worse--and longer lasting--than most policy makers and the public
    realize.
      --Early growth and development.--Having healthy baby teeth is vital
            to proper nutrition and speech development and sets the stage
            for a lifetime of dental health.
      --School readiness and performance.--In a single year, more than 51
            million hours of school may be missed because of dental-related
            illness.
      --Overall health.--A growing body of research indicates that
            periodontal disease--gum disease--is linked to cardiovascular
            disease, diabetes and stroke.
      --Economic consequences.--An estimated 164 million work hours each
            year are lost because of dental disease. Dental problems can
            hinder a person's ability to get a job in the first place
        Adequately funding Federal oral health programs will provide
    critical resources to States to plan, develop, coordinate, and operate
    cost-effective dental programs that prevent dental disease. Two ongoing
    Federal grant programs housed in the Centers for Disease Control and
    Prevention and the Human Resources and Services Administration directly
    support The Pew Campaign's goals, as do several new oral health
    prevention and workforce programs established by Public Law 111-148--
    Patient Protection and Affordable Care Act.
        The Pew Center on the States asks that the Subcommittee consider
    the following fiscal year 2011 funding requests:
        Support the expansion of established Federal grant programs:
      --CDC State Grants Program, Surveillance, and Technical Assistance--
            Division of Oral Health.--With CDC support, States can better
            promote oral health and efficiently administer scarce
            resources, monitor oral health status and problems, and conduct
            and evaluate prevention programs. This funding is critical to a
            State's ability to prevent problems before they occur, rather
            than treating them when they are painful and expensive. These
            programs also support State community water fluoridation
            programs and school-based dental sealant programs.
        For example, research shows that community water fluoridation
    offers one of the greatest return-on-investment of any preventive
    healthcare strategy. For most cities, every $1 invested in water
    fluoridation saves $38 in dental treatment costs. More than $1 billion
    could be saved annually if the remaining water supplies in the United
    States were fluoridated, according to the Centers for Disease Control.
        Pew supports expansion of this grant program to $33 million per
    year in order to reach all 50 States and the District of Columbia; an
    increase of $18 million more than the fiscal year 2010 appropriation.
        This program is authorized under section 4102 of Public Law 111-148
    as an amendment to the Public Health Service Act. Funding for this
    program fits the criteria for uses of the Public Health and Prevention
    Fund (fiscal year 2011 = $750 million). Please recommend and approve
    the transfer of $18 million of the Public Health and Prevention Fund to
    fulfill the program's authorization to support all 50 States.
        HRSA Dental Health Improvement Grants.--This program provides
    grants to States to support oral health workforce activities, under
    section 340G of the Public Health Service Act, and provide the
    opportunity for States to implement a range of innovative approaches to
    improve access to oral health services including, projects that address
    the oral health workforce needs of underserved areas in both urban and
    rural locations. For example, Florida used its Human Resources and
    Services Agency workforce grant for a task force that resulted in a
    regulatory change to expand the use of hygienists to improve the
    efficiency of sealant programs. Kansas is using these resources for
    several objectives, including promoting extended care permit
    utilization for dental hygienists and funding loan repayment programs
    for professionals working in underserved areas among other goals.
        Pew supports a grant program that is funded to reach all 50 States
    and the District of Columbia at a level of $20 million per year.
        Fully fund newly authorized or expanded oral health prevention
    programs in Public Law 111-148:
        School-based Sealant Programs--Establishment of school-based dental
    sealant programs.--The law requires that each of the 50 States and
    territories receive a grant for school-based dental sealant programs as
    well as to provide funding to Indian tribes. Sealants-clear plastic
    coatings applied by a hygienist or dentist-cost one-third as much as
    filling a cavity, and have been shown after just one application to
    prevent 60 percent of decay in molars. In The Cost of Delay, Pew finds
    that only 17 States have sealant programs that reach even one-quarter
    of their high-risk schools, and 11 reported having no programs at all.
        This program is authorized under section 4102 of Public Law 111-148
    as an amendment to the Public Health Service Act and is an eligible use
    of funding from the Public Health and Prevention Fund (fiscal year 2011
    = $750 million). Please recommend and approve the transfer of $312.5
    million of the Public Health and Prevention Fund to fulfill the program
    authorization to fund all 50 states. The estimated cost for fiscal year
    2011 provides for rapid acceleration and start-up funding along with
    information technology and evaluation. The annual costs in fiscal year
    2013 and beyond should be significantly less as the programs integrate
    with insurance payment options. This estimate assumes full funding of
    the CDC State Grants Program request (above) to support the additional
    expertise and management necessary for these programs.
        Alternative Dental Health Care Providers Demonstration Project.--
    The law establishes/authorizes a 5-year, demonstration program
    beginning within 2 years of enactment (no later than March 23, 2012) to
    train or employ alternative dental healthcare providers in order to
    increase access to dental healthcare services in rural and other
    underserved communities. Each grant shall equal not less than $4
    million (for the life of the project).
        Pew requests $16 million for the first year of this program with at
    least a 2-year period of availability. The $16 million will allow up to
    four eligible entities to plan and implement a demonstration project
    funded at $4 million over the 5-year project. Pew supports ramping up
    the appropriations for this program in fiscal year 2012 to support
    additional eligible entities to apply for demonstration projects.
        The U.S. Department of Health and Human Services has designated
    more than 4,000 areas across the country as Dental Health Professional
    Shortage Areas (DHPSAs). More than 46 million people live in DHPSAs
    across the United States, an estimated 30 million of whom lack access
    to a dentist.
        In 2006, roughly 4,500 new dentists graduated from the United
    States' 56 dental schools. But it would take more than 6,600 dentists
    choosing to practice in DHPSAs to provide care for those 30 million
    people. More than 10 percent of those are needed in Florida alone,
    where it would take at least 751 new dentists to close the access gap.
        These dentist shortages are projected to worsen. Although several
    dental schools have opened in the past few years, the number of
    dentists retiring every year will soon exceed the number of new
    dentists graduating and entering practice. In 2006, more than one-third
    of all practicing dentists were older the age of 55 and edging toward
    retirement. The Federal expansion of Medicaid and public insurance
    including dental services will also compound the relative shortage of
    dentists and further limit access to care. In 2009, Minnesota became
    the first state in the country to authorize a new primary care dental
    provider called a dental therapist at both a basic and advanced level.
    At least 12 States are considering similar models.
        Oral Healthcare Prevention Education Campaign.--The law establishes
    a 5-year national, public education campaign that is focused on oral
    healthcare prevention and education. The campaign is required to use
    science-based strategies to convey oral health prevention messages that
    include, but are not limited to, community water fluoridation and
    dental sealants.
        This program is authorized under section 4102 of Public Law 111-148
    as an amendment to the Public Health Service Act and is an eligible use
    of funding from the Public Health and Prevention Fund (fiscal year 2011
    = $750 million). Please recommend and approve the transfer of $2
    million of the Public Health and Prevention Fund to fulfill the program
    mandate. This estimate assumes that planning and testing of messages
    occurs during fiscal year 2011 while the major public education
    campaign would take place in fiscal year 2012 and beyond.
        In total the Pew Center on the States asks the committee to make
    the following investment in improving oral health for children in the
    fiscal year 2011 budget:

                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                  Amount
    ------------------------------------------------------------------------
    Total fiscal year 2011 request.........................            383.5
    Increase over 2010 appropriations for existing programs            351
    Amount of increase funded by the Prevention and Public             332.5
     Health Fund...........................................
    Increased investment in oral health out of the 302(b)               51
     subcommittee budget allocation........................
    ------------------------------------------------------------------------

        By making targeted Federal investments in effective policy
    approaches, States can help eliminate the pain, missed school hours and
    long-term health and economic consequences of untreated dental disease
    among kids. A handful of States are leading the way, but all States can
    and must do more to ensure access to dental care for America's children
    most in need. Thank you for your consideration of this testimony.
                                     ______

          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, and Health Resources and Services Administration. 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 pulmonary hypertension (PH) community.
        I particularly want to thank the subcommittee for the unprecedented
    support you provided to the NIH as part of the American Recovery and
    Reinvestment Act. PH research has benefited substantially from that
    investment with more than 17 PH-specific projects receiving ARRA
    funding.
        I am honored today to represent the hundreds of thousands of
    Americans who are fighting a courageous battle against a devastating
    disease. Pulmonary hypertension 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 impacts
    patients of all races, genders, and ages. Preliminary data from the
    REVEAL Registry suggests that the ratio of women to men who develop PH
    is 4:1. 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 Pulmonary Hypertension Association, 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.

                      THE PULMONARY HYPERTENSION COMMUNITY

        Mr. Chairman, I am privileged to serve as the President of the
    Pulmonary Hypertension Association 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 led
    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 30, 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 seven 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
    pulmonary hypertension 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 pulmonary
    hypertension 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 2011 APPROPRIATIONS RECOMMENDATIONS

    National Heart, Lung and Blood Institute
        In 2008, 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 seven 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.
        We are grateful to the National Heart, Lung and Blood Institute for
    their leadership in advancing research on PH. Our Association is proud
    to jointly sponsor investigator training grants (K awards) with NHLBI
    aimed at supporting the next generation of pulmonary hypertension
    researchers.
        Moreover, we were very pleased that NHLBI recently convened some of
    the community's leading scientists for a Working on Group on Pulmonary
    Hypertension. This panel is charged with developing recommendations
    that will guide PH research in the coming years. An overview of the
    Working Group's plan will be published in the American Journal of
    Respiratory and Critical Care Medicine this year and we encourage the
    subcommittee to support its implementation by NHLBI.
        Mr. Chairman, expanding clinical research remains a top priority
    for patients, caregivers, and PH investigators. We are particularly
    interested in establishing 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. We encourage the NHLBI to move forward with
    the establishment of a PH network in fiscal year 2011.
        For fiscal year 2011, PHA joins with other voluntary patient and
    medical organizations in recommending an appropriation of $35 billion
    for NIH. This level of funding will ensure continued expansion of
    research on rare diseases like pulmonary hypertension and build upon
    the significant investment made in the NIH as part of the American
    Recovery and Reinvestment Act.
    Centers for Disease Control and Prevention
        Mr. Chairman, we are grateful to you and the subcommittee for
    providing funding in fiscal year 2010 for the continuation of PHA's
    Pulmonary Hypertension Awareness Campaign. 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. More needs to be done to educate both the general public
    and healthcare providers if we are to save lives.
        To that end, PHA has utilized the funding provided through the CDC
    to: (1) launch a successful media outreach campaign focusing on both
    print and online outlets; (2) expand our support programs for
    previously underserved patient populations; and: (3) establish PHA
    Online University, an interactive curriculum-based Web site for medical
    professionals that targets pulmonary hypertension experts, primary care
    physicians, specialists in pulmonology/cardiology/rheumatology, and
    allied health professionals. The site is continually updated with
    information on early diagnosis and appropriate treatment of pulmonary
    hypertension. It serves as a center point for discussion among PH-
    treating medical professionals and offers Continuing Medical Education
    and CEU credits through a series of online classes.
    ``Gift of Life'' Donation Initiative at HRSA
        PHA applauds the success of the Health Resources and Services
    Administration'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 2011, PHA recommends an appropriation of $30 million for
    this important program.
                                     ______

               Letter from Public Health--Seattle and King County
                                                        March 19, 2010.
    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, Healthy and Human Services, and
            Education, and Related Agencies,
    Washington, DC.
        Dear Senators Harkin and Cochran: As a large public health agency
    serving King County, Washington we urge your subcommittee to invest in
    programs that provide all of our Nation's youth with comprehensive,
    medically accurate, and age-appropriate sex education that helps them
    reduce their risk of unintended pregnancy, HIV, and other sexually
    transmitted infections (STIs).
        For the first time in more than a decade, the Nation's teen
    pregnancy rate rose 3 percent in 2006. During this time, teens were
    receiving less information about contraception in schools and their use
    of contraceptives was declining. While making up only one-quarter of
    the sexually active population, young people aged 15-24 account for
    roughly half of the approximately 19 million new cases of STIs each
    year. Those aged 13-24 account for one-sixth of new HIV infections, the
    largest share of any group.
        We are pleased that the President's fiscal year 2011 budget request
    once again included funding for more comprehensive and evidence-based
    approaches to sex education. However, by focusing the funding on teen
    pregnancy prevention, and not including the equally important health
    issues of STIs including HIV, the administration has missed an
    opportunity to provide true, comprehensive sex education that promotes
    healthy behaviors and relationships for all young people, including
    lesbian, gay, bisexual, and transgender youth. We must strategically
    and systemically provide young people with all the information and
    services they need to make responsible decisions about their sexual
    health. Therefore, we request that the teen pregnancy prevention
    initiative be broadened to address STIs, including HIV, in addition to
    the prevention of unintended teen pregnancy.
        Most of the evidence-based programs that have been proven effective
    at reducing risk factors associated with unintended teenage pregnancy
    and STIs by delaying sexual activity and increasing contraceptive use
    emphasize abstinence as the safest choice and also discuss
    contraceptive use as a way to avoid pregnancy and sexually transmitted
    infections, including HIV. In light of the evidence and recognizing
    more than half of young people have had sexual intercourse by the age
    of 18 and are at risk of both unintended pregnancy and STIs, we request
    that the subcommittee direct the Office of Adolescent Health to
    prioritize funds to programs that are more comprehensive in scope
    insofar as they encourage abstinence but also encourage young people to
    always use condoms or other contraceptives when they are sexually
    active. Leading public health and medical professional organizations--
    including the American Medical Association, the American Academy of
    Pediatrics, the Society of Adolescent Medicine, and the American
    Psychological Association--support a comprehensive approach to
    educating young people about sex. In addition, the vast majority of
    parents want the Federal Government to fund programs that are medically
    accurate, age-appropriate, and educate youth about both abstinence and
    contraception.
        Congress should continue to act in the best interest of young
    people by supporting public health and education policies that are
    comprehensive, rooted in the best science, and reflect mainstream
    values. We urge you to include in the Subcommittee on Labor, Healthy
    and Human Services, and Education, and Related Agencies appropriations
    bill the strongest possible initiative that will meet the needs of all
    young people and help them achieve healthier and safer lives.
                Sincerely,
                               Matthew Golden, MD, MPH,
                                     Director, HIV/STD Program,
                                Public Health--Seattle and King County.
                                     ______

                    Prepared Statement of the PKD Foundation

        Mr. Chairman, Ranking Member, and members of the subcommittee:
    Thank you for the opportunity to provide testimony on behalf of the PKD
    Foundation and the more than 600,000 Americans and 12.5 million people
    world-wide suffering from polycystic kidney disease (PKD). This
    subcommittee's commitment to advancing the great work of the National
    Institutes of Health (NIH) is legendary, and it must be continued. To
    meet that need, the PKD Foundation supports funding NIH at $35 billion
    in fiscal year 2011. Underfunding NIH will only slow the pace and
    progress of scientific discoveries for PKD patients and all people
    living with a life-threatening disease or chronic condition.
        The PKD Foundation also supports an appropriation of $500 million
    to the newly authorized Cures Acceleration Network (CAN) as established
    under the Patient Protection and Affordable Care Act (Public Law 11-
    148; title X: sec. 10409). In order to help bridge the biomedical
    research ``valley of death,'' CAN and other innovative initiatives
    aimed at improving translational research and regulatory science at NIH
    must be fully funded.
    PKD Essentials
        Polycystic kidney disease or PKD is one of the world's most
    prevalent, life-threatening, genetic diseases affecting more than
    600,000 Americans including newborns, children and adults regardless of
    gender, age, race or ethnicity. With the presence of PKD, cysts develop
    in both kidneys, leading to an increase in kidney size and weight.
    Cysts can range in size from a pinhead to a grapefruit or a football.
    They may also cause a normal kidney to grow from the size of a person's
    fist to that of a football or a basketball and weigh as much as 38
    pounds each. Early in the disease, patients often do not experience
    symptoms and many do not realize they have PKD until other organs
    become affected. Deterioration in every PKD patient varies, but
    ultimately more than half will end up in renal failure and require
    dialysis or a kidney transplant. Currently, there is no treatment or
    cure for PKD.
    PKD Research Today
        PKD is the most therapy-ripe of all kidney diseases; research in
    PKD is progressive and robust. According to Dr. Francis Collins, NIH
    Director and former director of the Human Genome Research Institute,
    PKD research offers a tremendous ``return on investment.'' Dr. Collins
    called ``PKD [is] one of the hottest, most promising areas of research
    in all of biochemistry.'' In 1994, scientists discovered the genes that
    cause PKD, and currently, more than 20 clinical trials are underway to
    help uncover a treatment.
        Even with such success, PKD research is at a critical juncture.
    Akin to other diseases and chronic conditions, PKD researchers,
    patients and families are facing the biomedical research ``valley of
    death,'' the chasm in which basic research can languish. The ``valley
    of death'' is the point in the drug development pipeline where
    scientists work to develop prototype designs or invest in preclinical
    development. Because these processes are risky, funding is inconsistent
    and good ideas are often stopped in their tracks. The PKD Foundation
    seeks to overcome this chasm by developing systems to help advance and
    investing in translational research.
        The PKD Foundation believes there are three components necessary
    for bridging the ``valley of death.'' Those include: (1) purpose driven
    research with milestone gated research targets; (2) catalyzing and de-
    risking the drug development process to help encourage pharmaceutical
    and biotechnology companies and major donors to invest; and, (3)
    mobilizing impatient patients who will not accept the status quo.
    Efforts to Bridge the ``Valley of Death"
        On February 24, 2010, the NIH and the Food and Drug Administration
    (FDA) announced a collaborative initiative aimed at accelerating the
    drug development process by helping translate basic science into the
    availability of new and innovative drugs and devices. The NIH-FDA
    Initiative involves two interrelated scientific disciplines:
    translational research and regulatory science. Translational research
    involves shaping basic scientific discoveries into potential
    treatments. Regulatory science focuses on developing and using tools
    and standards to more efficiently aid in the development of therapeutic
    products. Improved regulatory science will help the FDA more
    effectively evaluate products for their safety and efficacy and help
    NIH scientists better understand what types of data and information
    should be collected for advancing basic research through the drug
    development process.
        The PKD Foundation fully supports this initiative and applauds the
    Department of Health and Human Services (HHS) for taking a bold step in
    addressing a lagging component in the drug development process. Both
    translational research and regulatory science are imperative for
    turning basic biomedical discoveries into therapies that will improve
    the health and well-being of patients. Providing a platform for purpose
    driven research is a necessary step in building a bridge over the
    ``valley of death.''
        In addition to the NIH-FDA Initiative on translational and
    regulatory science, the PKD Foundation applauds Congress for
    authorizing the Cures Acceleration Network (CAN) through the Patient
    Protection and Affordable Care Act. Housed within the Office of the
    Director of NIH, CAN will work to bridge the ``valley of death'' by
    helping identify and advance basic research via translational
    scientific discoveries through a new grant making system.
        The PKD Foundation is confident that the role and programmatic
    functions of CAN will help address the unmet needs of our impatient
    patients. We are optimistic that CAN will help catalyze and de-risk the
    drug development process, thereby encouraging pharmaceutical and
    biotechnology companies to reach back and invest in developing safe and
    effective therapies. In order to realize the great potential of CAN,
    the PKD Foundation urges the Subcommittee to fund CAN at its $500
    million authorizing level.
    Conclusion
        The NIH-FDA Initiative on translational and regulatory science and
    the Cures Acceleration Network are innovative ideas aimed at bridging
    the biomedical research ``valley of death.'' Coupling these innovative
    public endeavors with the efforts of private entities, such as the PKD
    Foundation's Drug Discovery Project, should help PKD patients and
    families rest a bit easier. Together we are working to advance the
    basic science and understanding of PKD, speed the discovery of
    treatments, and perhaps one day find a cure for PKD. To that end, the
    PKD Foundation supports $35 billion for NIH in fiscal year 2011 and
    $500 million for the Cures Acceleration Network. Funding NIH and its
    important initiatives and programs is one key to the future success of
    PKD research. Thank you.
                                     ______

                  Prepared Statement of ProLiteracy Worldwide

        Chairman Harkin, Vice Chairman Cochran, and members of the
    subcommittee, on behalf of the millions of adult learners working to
    improve their basic skills and pursue greater economic opportunity for
    themselves and their families, thank you for the opportunity to provide
    written testimony regarding the President's fiscal year 2011 budget
    request for adult education and family literacy, provided for under the
    Workforce Investment Act, title II. We would be pleased to testify and
    participate in any future hearings regarding adult literacy and basic
    education.
        At a time when millions of Americans are struggling to find work
    and billions of dollars are being invested in job creation and in
    retraining our workforce, it is essential to also invest in adult
    learning in order to maximize our return on these investments and put
    more American families on the road to self-sufficiency and economic
    security. We strongly urge you to provide at least $750 million for
    Adult Basic and Literacy Education in fiscal year 2011 to better assist
    the one in seven adults nationally who struggle with illiteracy.
    Background: ProLiteracy
        ProLiteracy Worldwide is the world's oldest and largest
    organization of adult literacy and basic education programs in the
    United States. ProLiteracy traces its roots to two premiere adult
    literacy organizations: Laubach Literacy International and Literacy
    Volunteers of America, Inc. In 2002, these two organizations merged to
    create ProLiteracy.
        ProLiteracy now represents more than 1,200 community-based
    organizations and adult basic education programs in the United States,
    and we partner with literacy organizations in 50 developing countries.
    In communities across the United States, these organizations use
    trained volunteers, teachers, and instructors to provide one on one
    tutoring, classroom instruction, and specialized classes in reading,
    writing, math, technology, English language skills, job-training and
    workforce literacy skills, GED preparation, and citizenship. Our
    members are located in all 50 States and in the District of Columbia.
    Through education, training and advocacy, ProLiteracy supports the
    frontline work of these organizations through regional conferences and
    other training events; credentialing; and the publication of materials
    and products used to teach adults basic literacy and English as a
    second language and to prepare adults for the U.S. citizenship exam and
    GED tests.
    The Urgent Need to Invest in Adult Education
        In 2003, the U.S. Department of Education conducted the National
    Assessment of Adult Literacy (NAAL) in order to gauge the English
    reading and comprehension skills of individuals in the United States
    older than the age of 16 on daily literacy tasks such as reading a
    newspaper article, following a printed television guide, and completing
    a bank deposit slip. The results indicated that 30 million adults--14
    percent of this country's adult population--had below basic literacy
    skills; that is, their ability to read was so poor, they could not
    complete a job application without help or follow the directions on a
    medicine bottle. An additional 63 million adults read only slightly
    better.
        Due to funding constraints, the adult education system currently
    only has the capacity to serve approximately 2.5 million of these 93
    million adults each year. Adult education has been nearly flat funded
    for a decade, seeing only a modest overall increase from 2001-2009.\1\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Education Budget History http://www2.ed.gov/
    about/overview/budget/history/edhistory.pdf.
    ---------------------------------------------------------------------------
        The high percentage of low-literate adults can be connected to
    almost every socioeconomic problem this country faces. According to the
    U.S. Department of Education, an estimated 60 percent of prison inmates
    are barely literate. Struggling readers are also more likely to be
    unemployed and require public assistance. Low literacy also has a
    significant impact on public health and healthcare costs. The 2003 U.S.
    Department of Education National Assessment of Adult Literacy (NAAL)
    estimates that 36 percent of the adult U.S. population has Basic or
    Below Basic health literacy levels. Low health literacy is a major
    source of economic inefficiency in the U.S. healthcare system: it is
    estimated that the cost of low health literacy to the U.S. economy is
    between $106 billion to $238 billion annually. This represents between
    7 percent and 17 percent of all personal healthcare expenditures.\2\
    ---------------------------------------------------------------------------
        \2\ Low health literacy: implications for national health policy.
    Available at: http://npsf.org/askme3/pdfs/Case_Report_10_07.pdf.
    ---------------------------------------------------------------------------
    The Proposed Adult Basic and Literacy Education Budget
        The proposed fiscal year 2011 budget includes several significant
    features that we strongly support. First, the President requested
    $612.3 million for State grants for adult education through the
    Workforce Investment Act (WIA), title II, an increase of $30 million
    compared to the 2009 appropriation. While ProLiteracy welcomes this
    overall increase to base funding, we agree with the National Coalition
    for Literacy's (of which we are a member) request for at least $750
    million for title II of WIA in fiscal year 2011, for the following
    reasons:
      --Although the President's proposal does increase base funding, it is
            actually a $15.9 million decrease from last year's total
            appropriation because of a one-time adjustment to correct for a
            funding calculation error that occurred from 2003-2008. Many
            States will receive a lower appropriation than in fiscal year
            2010, at a time when many States are dramatically cutting
            funding at the State and local levels due to budget deficits.
      --The President's proposal would not substantially increase the
            current number of students being served. We estimate that an
            increase to $750 million would serve an additional 500,000
            students--still a very small percentage of the millions of
            adults in the United States in need of adult literacy services,
            but a substantial and measurable boost in the number of adults
            ready to succeed in postsecondary education or occupational
            training.
      --We support the President's goal of having the highest proportion of
            college graduates in the world by the year 2020. However, even
            if every State's graduation rates reached the level of the
            highest-performing States, we cannot reach the President's goal
            without a substantial increase in the number of out of school
            adults entering into postsecondary education. Adult education
            and literacy programs are an important component in the
            development of a broader pipeline of learners entering into
            postsecondary education.
    Workforce Innovation
        In addition to an increase in State funding, the administration's
    budget includes a proposal to establish a new Partnership for Workforce
    Innovation between the Department of Labor (DOL) and the Department of
    Education (ED), providing a total of $321 million to support jointly
    administered competitive Adult and Youth Innovation grants to States
    and localities to test and replicate innovative workforce practices. A
    $30 million increase to the Office of Vocational and Adult Education's
    (OVAE) National Leadership funding represents OVAE's contribution to
    the fund.
        ProLiteracy applauds the administration's commitment to innovation.
    We urge the subcommittee to ensure that innovation funding will benefit
    adults at all skill levels, particularly the millions who are estimated
    to possess less than basic literacy skills. In order for these adults
    benefit from this fund, we recommend the following:
      --Both the Adult and Youth Workforce Innovation Funds should
            encourage integration between title I and II programs.
        The Workforce Innovation Fund is a unique opportunity for the DOL
    and ED to develop coordinated approaches to build upon what works at a
    scale that can make a tangible difference to jobseekers. We suggest
    that the DOL and ED funds be combined to expand successful, integrated
    approaches to serving the lowest level learners and ensure eligible
    entities under this funding stream have a demonstrated capacity of
    serving adult learners.
        Adult education providers should also be eligible to apply for the
    funding contributed by DOL to both the Workforce Innovation Fund and
    the Youth Innovation Fund. This would help address a common criticism
    that Workforce Investment Act title I and II programs are too
    disconnected from each other and fail to provide well-integrated
    workforce development and adult education services. Grants to local
    adult literacy providers, working in partnership, for example, with
    local workforce investment boards, could develop more effective
    replicable practices to improve the lowest level learners placement and
    retention in employment.
        We also recommend that any definition of underserved populations in
    the DOL Workforce Innovation Fund include adult learners, particular
    those at the lowest levels of literacy, and that eligible entities
    under this funding stream should include those with a demonstrated
    capacity of serving adult learners via services that are linked to
    income, work, and academic supports and to better connect these systems
    with employers and postsecondary education.
        Also, because a significant number of young adults ages 16-24
    receive education services from adult education programs, we recommend
    that the DOL's Youth Innovation Fund explicitly define adult and family
    literacy services as an allowable education activity under this funding
    stream.
      --Eligibility for Workforce Innovation Fund grants should include
            community-based organizations and other entities with
            demonstrated capacity to assist adults at the lowest literacy
            levels and their families, and include wraparound services.
      --The need for innovation should not come at the expense of the
            existing WIA title II formula funds.
        As noted above, while the President is calling for an overall
    increase to base funding, some States will receive a substantially
    smaller appropriation--at a time when many States are dramatically
    cutting funding at the State and local level due to budget deficits.
    ProLiteracy urges the subcommittee to ensure that the Workforce
    Innovation Fund is funded on top of annual WIA formula funds, rather
    than as a carve out of existing formula funds.
        Thank you for the opportunity to present this testimony. We would
    be happy to respond to any questions that you may have.
                                     ______

              Prepared Statement of the Railroad Retirement Board

        Mr. Chairman and members of the subcommittee: We are pleased to
    present the following information to support the Railroad Retirement
    Board's (RRB) fiscal year 2011 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 the past
    year, the RRB has also administered special economic recovery payments
    and extended unemployment benefits under the American Recovery and
    Reinvestment Act of 2009 (ARRA), and more recently, extended
    unemployment benefits under the Worker, Homeownership, and Business
    Assistance Act of 2009.
        During fiscal year 2009, the RRB paid $10.5 billion, net of
    recoveries, in retirement/survivor benefits and vested dual benefits to
    about 589,000 beneficiaries. We also paid $154.1 million in net
    unemployment/sickness insurance benefits under the Railroad
    Unemployment Insurance Act to more than 40,000 claimants. In addition,
    the RRB paid benefits on behalf of the Social Security Administration
    amounting to $1.3 billion to about 115,000 beneficiaries, and we paid
    about $129.5 million in Economic Recovery Payments and $10.3 million in
    temporary extended unemployment benefits under ARRA to about 518,700
    beneficiaries and 3,100 claimants, respectively.

                   PROPOSED FUNDING FOR AGENCY ADMINISTRATION

        The President's proposed budget would provide $110,573,000 for
    agency operations, which would enable us to maintain a staffing level
    of 891 full-time equivalent staff years in 2011. The proposed budget
    would also provide $1,500,000 for information technology investments.
    This includes $850,000 for costs related to an upgrade of the agency's
    mainframe computer. The remaining IT funds would be used for
    information security and privacy, E-Government initiatives, systems
    modernization, network operations, and some infrastructure replacement.

                                AGENCY STAFFING

        The RRB's dedicated and experienced workforce is the foundation for
    our tradition of excellence in customer service and satisfaction. Like
    many Federal agencies, however, the RRB has a number of employees at or
    near retirement age. Nearly 70 percent of our employees have 20 or more
    years of service at the agency, and about 40 percent of the current
    workforce will be eligible for retirement by fiscal year 2012.
        To prepare for expected staff turnover in the near future, we are
    focusing on activities related to workforce planning and development.
    During the past year, the agency drafted a formal human capital plan
    that adheres to guidance issued by the Office of Personnel Management.
    The plan identifies demographic features of the agency's workforce and
    the skills needed to fulfill our mission. The plan also establishes a
    framework of actions over the next few years to recruit, retain, and
    develop talented employees. We have also drafted a succession plan that
    specifies staffing needed to meet organizational goals, identifies
    competency gaps and develops strategies to address overall human
    capital needs.
        In connection with these workforce planning efforts, our budget
    request for fiscal year 2011 includes a legislative proposal to enable
    the RRB to utilize various hiring authorities available to other
    Federal agencies. Section 7(b)(9) of the Railroad Retirement Act
    contains language requiring that all employees of the RRB, except for
    one assistant for each board member, must be hired under the
    competitive civil service. We propose to eliminate this requirement,
    thereby enabling the RRB to use various hiring authorities offered by
    the Office of Personnel Management.

                      INFORMATION TECHNOLOGY IMPROVEMENTS

        In recent 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. In
    fiscal year 2009, we began a multi-year initiative to modernize our
    application systems, starting with Medicare processing systems. This
    effort will enable the RRB to maintain the capability of our business
    operations in the event of expected staff turnover, and to upgrade
    agency systems by building on the improvements that we have already
    completed. Much of the work related to this initiative will be
    completed by in-house staff. Our budget request for fiscal year 2011
    includes $150,000 for minimal contractual services related to the
    initiative.
        In order to keep pace with these planned improvements, it will be
    necessary to increase the capacity of our mainframe computer. In fiscal
    year 2008, a new mainframe computer was installed with scalability to
    provide for additional processing capacity as demand increases. Since
    then, demand for additional processing capacity has increased an
    average of 18 percent each year with the completion of various
    automation initiatives. Our fiscal year 2011 budget request includes
    $850,000 to upgrade the RRB's mainframe computer software in order to
    meet the rising demand for capacity.
        Our proposed budget also includes an additional $500,000 for other
    information technology investments. This funding will provide for
    essential equipment and services needed to maintain our network
    operations and infrastructure in fiscal year 2011, and to continue with
    other initiatives, such as E-Government and information security and
    privacy.
        The President's proposed budget includes $57 million to fund the
    continuing phase-out of vested dual benefits, plus a 2 percent
    contingency reserve, $1,140,000, 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 Web site.
    The market value of Trust-managed assets on September 30, 2009, was
    approximately $23.3 billion, a decrease of $2 billion from the previous
    year. Since its inception, the Trust has transferred approximately $8.9
    billion to the RRB for payment of railroad retirement benefits.
        In June 2009, we released the 24th Actuarial Valuation, including
    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 actuarial valuation
    indicates that cash flow problems occur only under the most pessimistic
    assumption. Even under that assumption, the cash flow problems do not
    occur until the year 2031. The long-term stability of the system,
    however, is not assured. Under the current financing structure, actual
    levels of railroad employment and investment performance over the
    coming years will determine whether additional corrective action is
    necessary.
        Railroad Unemployment Insurance Account.--The equity balance of the
    Railroad Unemployment Insurance (RUI) Account at the end of fiscal year
    2009 was $27.8 million, a decrease of $72.1 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 2009. The
    report indicated that even as maximum daily benefit rates rise 43
    percent (from $61 to $87) from 2008 to 2019, experience-based
    contribution rates are expected to keep the unemployment insurance
    system solvent, except for small, short-term cash flow problems in 2010
    and 2011 under the moderate and pessimistic assumptions. Projections
    show a quick repayment of loans even under the most pessimistic
    assumption.
        Unemployment levels are the single most significant factor
    affecting the financial status of the railroad unemployment insurance
    system. However, the system's experience-rating provisions, which
    adjust contribution rates for changing benefit levels, and its
    surcharge trigger for maintaining a minimum balance, help to ensure
    financial stability in the event of adverse economic conditions. No
    financing changes were recommended at this time by the report.
        Due to the increased level of unemployment insurance payments
    during fiscal year 2009 and anticipated for fiscal year 2010, loans
    from the Railroad Retirement (RR) Account to the RUI Account became
    necessary beginning in December 2009. Transfers from the RR Account to
    the RUI Account through February 2010 amounted to $24.5 million.
    Current projections indicate that additional loans from the RR Account
    to the RUI Account during fiscal year 2010 could amount to
    approximately $43.5 million, for a total of $68 million during the
    fiscal year.
        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. I would like to thank you, Mr. Chairman, and the members of the
    subcommittee for your continued support of the Office of Inspector
    General.
                   budget request and background information
        I wish to describe our fiscal year 2011 appropriations request and
    our planned activities. The Office of Inspector General (OIG)
    respectfully requests funding in the amount of $8,936,000 to ensure the
    continuation of its independent oversight of the Railroad Retirement
    Board (RRB).
        The RRB's central mission is to pay accurate and timely benefits.
    During fiscal year 2009, the RRB paid approximately $10.5 billion in
    retirement and survivor benefits to 589,000 beneficiaries. RRB also
    paid roughly $154.1 million in net unemployment and sickness insurance
    benefits to almost 24,000 unemployment insurance beneficiaries and
    18,000 sickness insurance beneficiaries.
        The RRB contracts with a separate Medicare Part B carrier, Palmetto
    GBA, to process the Medicare Part B claims of qualified railroad
    retirement beneficiaries. As of September 30, 2009, there were about
    468,000 such beneficiaries enrolled in the Medicare Part B program
    through the RRB. During fiscal year 2009, Palmetto, GBA paid over $900
    million in benefits.
        During fiscal year 2011, the OIG will focus on areas affecting
    program performance; the efficiency and effectiveness of agency
    operations; and areas of potential fraud, waste, and abuse.

                             OPERATIONAL COMPONENTS

        The OIG has three operational components: the immediate Office of
    the Inspector General, the Office of Audit (OA), and the Office of
    Investigations (OI). The OIG conducts operations from several
    locations: the RRB's headquarters in Chicago, Illinois; an
    investigative field office in Philadelphia, Pennsylvania; and three
    domicile investigative offices located in Arlington, Virginia; Houston,
    Texas; and San Diego, California. These domicile offices provide more
    effective and efficient coordination with other Inspector General
    offices and traditional law enforcement agencies with which the OIG
    works joint investigations.

                                OFFICE OF AUDIT

        It is OA's mission to:
      --promote economy, efficiency, and effectiveness in the
            administration of RRB programs and
      --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 2011, 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, including activities of
            Palmetto, GBA; and
      --Security, privacy, and information management.
        During fiscal year 2011, 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 2011, OA will complete the audit of the RRB's
    fiscal year 2010 financial statements and begin its audit of the
    agency's fiscal year 2011 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 fiscal year 2011, the
    cost of this contract is expected to increase significantly over the
    current contract amount.
        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 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's investigative results for fiscal year 2009 are:

    ------------------------------------------------------------------------
                              Item                                Amount
    ------------------------------------------------------------------------
    Civil judgments.........................................              29
    Indictments/informations................................              78
    Convictions.............................................              48
    Recoveries/collections..................................      $7,056,086
    ------------------------------------------------------------------------

        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 and the Social Security
    Administration with RRB benefits paid data. 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 Office of
    Audit.
        Presently, disability and Railroad Medicare fraud cases constitute
    more than 60 percent of OI's total caseload. These cases often involve
    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 surveillance,
    numerous witness interviews, or more sophisticated investigative
    techniques. Additionally, these fraud investigations are extremely
    document-intensive and involve complicated financial analysis.
        During fiscal year 2011, OI anticipates an ongoing caseload of more
    than 400 investigations. 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.

                                   CONCLUSION

        In fiscal year 2011, 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's 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 its 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

                                  INTRODUCTION

        I am Dr. Kathleen Clanon, an HIV physician and Medical Director of
    the HIV ACCESS program in Oakland, California. I am submitting written
    testimony on behalf of the Ryan White Medical Providers Coalition.
        Thank you for the opportunity to discuss the important HIV/AIDS
    care conducted at Ryan White Part C-funded programs nationwide.
    Specifically, the Ryan White Medical Provider Coalition, the HIV
    Medicine Association, the CAEAR Coalition, and the American Academy of
    HIV Medicine estimate that approximately $407 million is needed to
    provide the standard of care for all part C program patients. (This
    estimate is based on the current cost of care and the number of
    patients that part C clinics serve.) While these are exceptionally
    challenging economic times, we request $338 million for Ryan White Part
    C programs in fiscal year 2011. This $131 million funding increase
    would help meet the goal of providing the standard of care to all
    patients who need it.
        The Ryan White Medical Providers 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. We speak for those who often
    cannot speak for themselves and we advocate for a full range of primary
    care services for these patients. Sufficient funding for part C is
    essential to providing appropriate care for individuals living with
    HIV/AIDS.
        Part C of the Ryan White Program funds comprehensive HIV care and
    treatment, services that are directly responsible for the dramatic
    decreases in AIDS-related mortality and morbidity over the last decade.
    The Centers for Disease Control and Prevention estimate that there are
    more than 1.1 million persons living with HIV/AIDS, and in 2008
    approximately 240,000, or almost 1 in 4, of these individuals received
    services from part C medical providers--a dramatic 30 percent increase
    in patients in less than 10 years.
        The recent passage of healthcare reform is a great achievement, but
    many of the legislation's provisions and programs will not take effect
    for several years. In the meantime, part C clinics need additional
    resources today to continue delivering lifesaving and cost-effective
    care to the growing number of people living with HIV.

        THE COST OF CARE IS REASONABLE; THE REIMBURSEMENT FOR CARE ISN'T

        On average it costs $3,501 per person per year to provide the
    comprehensive outpatient care and treatment available at part C-funded
    programs, including lab work, STD/TB/Hepatitis screening, ob/gyn care,
    dental care, mental health and substance abuse treatment, and case
    management. Part C funding covers only a small percentage of the total
    cost of this comprehensive care, with some programs receiving $450 (12
    percent of the total cost) or less per patient per year to cover the
    cost of care.

                   PART C PROGRAMS SAVE BOTH LIVES AND MONEY

        Investing in part C services improves lives and saves money. In the
    United States, nearly 50 percent of persons living with HIV/AIDS who
    are aware of their status are not in regular care. Early and reliable
    access to HIV care and treatment both helps patients with HIV live
    relatively healthy and productive lives and is more cost effective. One
    study from the Part C Clinic at the University of Alabama at Birmingham
    found that patients treated at the later stages of HIV disease required
    2.6 times more healthcare dollars than those receiving earlier
    treatment meeting Federal HIV treatment guidelines.

             PATIENT LOADS ARE INCREASING AT AN UNSUSTAINABLE RATE

        Patient loads have been increasing at part C clinics nationwide,
    despite the fact that there has not been significant new Federal
    funding, and in many cases, State and/or local funding has been cut. A
    steady increase in patients has occurred on account of higher diagnosis
    rates and declining insurance coverage resulting in part from the
    economic downturn. The CDC reports that the number of HIV/AIDS cases
    increased by 15 percent from 2004 to 2007 in 34 States.\1\
    ---------------------------------------------------------------------------
        \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/.
    ---------------------------------------------------------------------------
        For example, a clinic in Henderson, North Carolina, has seen its
    patient load increase almost nine fold from 35 patients in 2000 to
    nearly 300 today, yet the clinic is receiving less funding now than 10
    years ago. This clinic is the only facility of its kind for people with
    HIV within 45 miles and it is struggling to deliver the complex care
    these patients need. At another clinic in Greensboro, North Carolina,
    the number of patients more than doubled from 321 patients in 2002 to
    more than 800 in 2009. The clinic continues to deliver care in the same
    space with the same staffing as in 2002 despite the 250 percent
    increase in patients. Meeting this growing demand requires the maximum
    effort of existing staff, and position vacancies prevented enrollment
    of new patients for several months during 2009. In Sonoma County,
    California, funding has become so scarce that the Part C Clinic there
    is closing its doors, forced to patch together new medical homes in
    other locations for 350 patients.
        Our patients struggle in times of plenty, and during this economic
    downturn they have relied on part C programs more than ever. While
    these programs have been underfunded for years, State and local
    economic pressures are creating a crisis in our communities. Clinics
    are discontinuing primary care and other critical medical services,
    such as laboratory monitoring; suffering eviction from their clinic
    locations; operating only 4 days per week; and laying off staff just to
    get by. Years of nearly flat funding combined with large increases in
    the patient population and the recent economic crisis are negatively
    impacting the ability of part C providers to serve their patients.
        The following graph demonstrates the growing disparity between
    funding for part C and the increasing patient population. I refer to
    this gap between funding and patients as the ``Triangle of Misery''
    because it represents both the thousands of patients who deserve more
    than we can offer and the part C programs nationwide that are
    struggling to serve them with shrinking resources.

                                   CONCLUSION

        These are challenging economic times, and we recognize the severe
    fiscal constraints Congress faces in allocating limited Federal
    dollars. However, Congress itself has recognized the need to
    substantially increase part C funds in its recent passage of the
    reauthorization of the Ryan White Program in September 2009. In this
    law, Congress recommended funding Ryan White Part C Programs at $259
    million in fiscal year 2011, a $52 million increase more than the
    fiscal year 2010 funding level.
        The significant financial and patient pressures that we face in our
    clinics at home propel us to request a substantial Federal investment
    of $338 million in fiscal year 2011 for Ryan White Part C programs to
    support medical providers nationwide in delivering appropriate and
    effective HIV/AIDS care to their patients. Thank you for your time and
    consideration of our request.
                                     ______

      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 2011 to help improve quality-of-life for
    people with Spina Bifida:
      --$7.5 million for the National Spina Bifida Program within 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.
      --$5.126 million for the CDC's national folic acid education and
            promotion efforts to support the prevention of Spina Bifida and
            other neural tube defects.
      --$26.342 million to strengthen the CDC's National Birth Defects
            Prevention Network.
      --$163.5 million in overall funding for the CDC's National Center on
            Birth Defects and Developmental Disabilities.
      --$611 million for the Agency for Healthcare Research and Quality
            (AHRQ).
      --$32.2 billion for the National Institutes of Health (NIH) to
            support biomedical research.

                            BACKGROUND AND OVERVIEW

        On behalf of the estimated 166,000 individuals and their families
    who are affected by all forms of 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 2011 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 SBF
    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.
        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, such as transitioning from
    pediatric to adult healthcare providers, 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, 3,000
    pregnancies are affected by Spina Bifida, resulting in 1,500 babies
    born each year with the condition, 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. 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

        Since, 2001, SBA has worked with Members of Congress and staff at
    the CDC 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 National Spina Bifida Program established the National Spina
    Bifida Resource Center housed at the SBA, which provides 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 given the
    skills and information they need 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 166,000 individuals living with all forms of Spina
    Bifida, with the goal being living well with Spina Bifida.
        An important resource to better determine best clinical practices
    and the most cost effective treatments for Spina Bifida is the National
    Spina Bifida Registry, now in its second year. Nine sites throughout
    the Nation are collecting patient data, which supports the creation of
    quality measures and will assist in improving clinical research that
    will truly save lives, while also realizing a significant cost savings.
        In fiscal year 2010, SBA requested that $7 million be allocated to
    support and expand the National Spina Bifida Program. In the final
    fiscal year 2010 Omnibus Appropriations Act, Congress provided $6.242
    million for this program, a slight increase 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 $7.5 million in fiscal year 2011 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. 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.
        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. 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. 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 2011, 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 $7.5 million fiscal year 2011 allocation for the
    National Spina Bifida Program, SBA urges the subcommittee to provide
    $5.126 million for the CDC's national folic acid education and
    promotion efforts to support the prevention of Spina Bifida and other
    neural tube defects; $26.342 million to strengthen the CDC's National
    Birth Defects Prevention Network; and $163.5 million to fund 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 $611 million fiscal year 2011 allocation for AHRQ, so it can
    continue to provide guidance and support to the National Spina Bifida
    Patient Registry and help improve quality of care and outcomes for
    people with Spina Bifida.

             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 increased
    funding in fiscal year 2011. 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 the following
    language in the report accompanying the fiscal year 2011 LHHS
    appropriations measure:

        ``The Committee encourages NIDDK, NICHD, and NINDS to study the
    causes and care of the neurogenic bladder in order to improve the
    quality of life of children and adults with Spina Bifida; to support
    research to address issues related to the treatment and management of
    Spina Bifida and associated secondary conditions, such as
    hydrocephalus; and to invest in understanding the myriad co-morbid
    conditions experienced by children with Spina Bifida, including those
    associated with both paralysis and developmental delay.''

                                   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 2011 funding for programs that will improve the quality-of-
    life for the 166,000 Americans and their families living with all forms
    of Spina Bifida.
                                     ______

                     Prepared Statement of Status C Unknown

        Status C Unknown (SCU) is a nonprofit organization. SCU's mission
    is to educate those impacted by HCV about treatment options and promote
    enhanced HCV awareness among the general public, healthcare
    communities, and policymakers. Our strategic focus is prevention
    education, support and advocacy. We are a multi-program organization
    with primary focus on legislative activities and programs, both
    statewide and nationally. We have led the way in hepatitis C advocacy
    since 2005 in collaboration and partnerships with other community based
    organizations, service providers, New York State Department of Health
    (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC
    DOHMH).
        As you craft the fiscal year 2011 Labor-HHS-Education
    appropriations legislation, we urge you to consider the following
    critical funding needs of viral hepatitis programs:
        Specific funding needs:
      --We are requesting an increase of $30.7 million for a total of $50
            million for the Centers for Disease Control and Prevention
            (CDC) Division of Viral Hepatitis (DVH).
      --At least $20 million for an adult hepatitis B vaccination
            initiative through the CDC Section 317 Vaccine Program.
      --$10 million for the Substance Abuse and Mental Health Services
            Administration (SAMHSA) to fund a project within the Programs
            of Regional and National Significance (PRNS) to reach persons
            who use drugs with viral hepatitis prevention services.
        General funding needs:
      --Increase funding for Community Health Centers to increase their
            capacity to serve people with chronic viral hepatitis;
      --Increase funding for the Ryan White Program to adequately cover
            persons co-infected with viral hepatitis through additional
            case management, provider education and coverage of viral
            hepatitis drug therapies;
      --Increase funding for the National Institutes of Health to support
            their Action Plan for Liver Disease Research.
    Specific Funding Needs
                Division of Viral Hepatitis--Fiscal Year 2011 Request:
                        $30.7 million
        The recently released Institute of Medicine (IOM) report,
    ``Hepatitis and Liver Cancer: A National Strategy for Prevention and
    Control of Hepatitis B and C'' found that the public health response
    needs to be significantly ramped up. The IOM report attributes low
    public and provider awareness to the lack of public resources.
    Seventeen of the 22 recommendations in the report are specific to CDC
    DVH and State health departments. In order to implement these
    recommendations to improve the Federal response, resources must be
    increased to health departments which are the backbone of the Nation's
    public health system and coordinate the response to these epidemics.
        President Obama's budget proposal includes a $1.8 million increase
    for the Division of Viral Hepatitis (DVH) at CDC, which is woefully
    insufficient to address infectious diseases of this magnitude. While
    operating on the smallest Division budget for the prevention of
    infectious diseases within CDC, DVH will never be able to sufficiently
    prevent and manage these epidemics under its current fiscal
    constraints. States and cities receive an average funding award from
    DVH of $90,000. This is only enough for a single staff position and is
    not sufficient for the provision of core prevention services. These
    services are essential to preventing new infections, increasing the
    number of people who know they are infected, and following up to help
    those identified to remain healthy and productive. We believe this
    increase is an important first step to making hepatitis prevention
    services more widely available. The expanded services should include
    hepatitis B and C education, counseling, testing, and referral in
    addition to delivering hepatitis A and B vaccine, and establishing a
    surveillance system of chronic hepatitis B and C.
                Section 317 Vaccine Program--Fiscal Year 2011 Request: $20
                        million
        CDC identified funds through program cost savings in the Section
    317 Vaccine Program, allocating $20 million in fiscal year 2008 and $16
    million in fiscal year 2009 for purchase of the hepatitis B vaccine for
    high-risk adults. We commend CDC for prioritizing high-risk adults with
    this initiative, but relying on the availability of these cost savings
    is not enough. Additionally, this initiative does not support any
    infrastructure or personnel and health departments need additional
    funding to support the delivery of this vaccine. We request a
    continuation of $20 million in fiscal year 2011 for an adult hepatitis
    B vaccination initiative through the CDC's Section 317 Vaccine Program.
                Substance Abuse and Mental Health Services Administration--
                        Fiscal Year 2011 Request: $10 Million
        Persons who use drugs are disproportionately impacted by hepatitis
    B and C. The Substance Abuse and Mental Health Services Administration
    (SAMHSA) Center for Substance Abuse Prevention (CSAP) and Center for
    Substance Abuse Treatment (CSAT) are uniquely positioned to reach
    populations at risk for hepatitis B and C. The existing infrastructure
    of substance abuse prevention and treatment programs in the United
    States provides an important opportunity to reach Americans at risk or
    living with viral hepatitis. We urge you to provide $10 million to
    SAMHSA to fund a project within the Programs of Regional and National
    Significance (PRNS) to reach persons who use drugs with viral hepatitis
    prevention services.
    General Funding Needs
                Medical Management and Treatment
        Access to available treatments and support services are critical to
    combat viral hepatitis mortality. While we are supportive of the
    President's efforts to modernize and expand access to healthcare, we
    also support increased funding for existing safety net programs. Low-
    income patients who are uninsured or underinsured can and do seek
    services at Community Health Centers (CHCs). With the growing
    importance of CHCs as a safety net in providing frontline support for
    these individuals, we support increasing resources for CHCs to increase
    their capacity to serve people with chronic viral hepatitis.
        Many low-income individuals co-infected with viral hepatitis and
    HIV can obtain services through the Ryan White Program, however only
    half of the State AIDS Drug Assistance Programs (ADAPs) are able to
    provide viral hepatitis treatments to co-infected clients. We urge you
    to increase Ryan White funding so States can provide adequate coverage
    for co-infected clients. Increased resources are also needed to improve
    provider education on viral hepatitis medical management and treatment,
    to cover additional case management for patients undergoing treatment
    and to allow more states to add viral hepatitis therapies and viral
    load tests to their ADAP formularies. While Ryan White providers offer
    lifesaving care to co-infected clients, they also have the expertise
    and infrastructure to provide limited services to viral hepatitis mono-
    infected clients.
                Research
        Finally, research is needed to increase understanding of the
    pathogenesis of hepatitis B and C. Further research to improve
    hepatitis B and C treatments that are currently difficult to tolerate
    and have low ``cure'' rates are also needed. The development of
    clinical strategies to slow the progression of liver disease among
    persons living with chronic infection, especially to those who may not
    respond to current treatment must be addressed. With effective vaccines
    against hepatitis A and B, it is important to continue to work towards
    the development of a vaccine against hepatitis C infection. The Liver
    Disease Branch, located within the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH), has developed an Action Plan for Liver Disease Research.
    We request full funding for NIH to support the recommendations and
    action steps outlined in this Action Plan for Liver Disease Research.
        It is absolutely essential and urgent that we act aggressively to
    address the threat of viral hepatitis in the United States. In 2007
    alone, the CDC estimated that 43,000 Americans were newly infected with
    hepatitis B and 17,000 with hepatitis C. Unfortunately, it is believed
    that these estimates of hepatitis B and C infections are just the tip
    of the iceberg. Most people living with hepatitis B and more than
    three-fourths of people living with hepatitis C do not know that they
    are infected. It is estimated that the baby boomer population currently
    accounts for two out of every three cases of chronic hepatitis C. It is
    also estimated that this epidemic will increase costs by billions of
    dollars to our private insurers and public systems of health such as
    Medicare and Medicaid, and account for billions lost due to decreased
    productivity from the millions of American workers suffering from
    chronic hepatitis B and C.
        As you continue to draft the fiscal year 2011 Labor, Health and
    Human Services, and Education, and Related Agencies appropriations
    bill, we ask that you consider a generous increase for viral hepatitis
    prevention to counter several years of flat or inadequate growth in
    funding. A strong public health response is needed to meet the
    challenges of these costly infectious diseases. The viral hepatitis
    community welcomes the opportunity to work with you and your staff on
    this important issue.
                                     ______

               Prepared Statement of the Society for Neuroscience

                                  INTRODUCTION

        Mr. Chairman and Members of the Subcommittee, I am Michael E.
    Goldberg, M.D. I am the David Mahoney Professor of Brain and Behavior,
    in the Departments of Neuroscience, Neurology, Psychiatry, and
    Ophthalmology; as well as the Director of the Mahoney-Keck Center for
    Brain and Behavior Research at Columbia University and President of the
    Society for Neuroscience (SfN). My area of specialization is the
    physiology of cognitive processes: visual attention, spatial
    perception, and decisionmaking.
        On behalf of the 40,000 members of the Society for Neuroscience, I
    would like to thank you for your past support of neuroscience research
    at the National Institutes of Health (NIH). Research funded by NIH has
    returned significant dividends in terms of improved patient care as
    well as the development of prevention programs for brain and nervous
    system disorders. In this testimony, I will highlight how taxpayers
    have benefited from this investment, and how a sustained investment can
    enhance medical research, health, and economic strength.

                        FISCAL YEAR 2011 BUDGET REQUEST

        The entire scientific community is deeply grateful for the historic
    investment in NIH through the American Recovery and Reinvestment Act
    (ARRA), which is now funding high quality research, while creating and
    preserving jobs. This investment in innovation and science is not only
    setting a path to new discoveries, but also helping to stimulate the
    national and local economies, preserving or creating an estimated
    50,000 new high-wage, hi-tech jobs at a critical time for U.S.
    research, and producing an estimated 2.5 return on investment for local
    communities. To continue this exciting scientific and economic momentum
    and maintain the current research capacity, the Society respectfully
    requests that Congress provide a fiscal year 2011 appropriation in the
    amount of $35 billion for NIH. This level of funding will build on the
    research activities supported by the regular 2010 appropriations and
    ensure that the Nation's universities do not lose scientific ground,
    and be forced to lay off thousands of U.S. scientists and their support
    staffs, when the ARRA funding ends this year. A strong investment in
    the scientific enterprise will ensure that there is not a dramatic drop
    in research activity and more job losses, as well as serve strong
    encouragement to keep our young researchers in the training pipeline
    and keep the programmers, technicians, and engineers so critical to
    biomedical research in their jobs.

                     WHAT IS THE SOCIETY FOR NEUROSCIENCE?

        The Society for Neuroscience (SfN) is a nonprofit membership
    organization of basic scientists and physicians who study the brain and
    nervous system. SfN's mission is to:
      --Advance the understanding of the brain and the nervous system.
      --Provide professional development activities, information, and
            educational resources for neuroscientists at all stages of
            their careers.
      --Promote public information and general education about the nature
            of scientific discovery and the results and implications of the
            latest neuroscience research.
      --Inform legislators and other policymakers about new scientific
            knowledge and recent developments in neuroscience research and
            their implications for public policy, societal benefit, and
            continued scientific progress.

                             WHAT IS NEUROSCIENCE?

        Neuroscience is the study of the nervous system--including the
    brain, the spinal cord, and networks of sensory nerve cells, or
    neurons, throughout the body. Humans contain roughly 100 billion
    neurons, the functional units of the nervous system. Neurons
    communicate with each other by sending electrical signals long
    distances and then releasing chemicals called neurotransmitters which
    cross synapses--small gaps between neurons.
        The nervous system consists of two main parts. The central nervous
    system is made up of the brain and spinal cord. The peripheral nervous
    system includes the nerves that serve the neck, arms, trunk, legs,
    skeletal muscles, and internal organs.
        Critical components of the nervous system are molecules, neurons,
    and the processes within and between cells. These are organized into
    large neural networks and systems controlling functions such as vision,
    hearing, learning, breathing, and, ultimately, all of human behavior.
        Through their research, neuroscientists work to:
      --Describe the human brain and how it functions normally.
      --Determine how the nervous system develops, matures, and maintains
            itself through life.
      --Find ways to prevent or cure many devastating neurological and
            psychiatric disorders.

                      NIH-FUNDED BRAIN RESEARCH SUCCESSES

        The funds provided in the past have helped neuroscientists make
    significant progress in diagnosing and treating neurological disorders.
    Today, thanks to NIH-funded research, scientists and healthcare
    providers have a much better understanding of how the brain functions.
        The following are a few of the many success stories in neuroscience
    research:
      --Post-traumatic Stress Disorder (PTSD).--For years it was thought
            that those who survived or witnessed a trauma should be able to
            tough it out and move on. But scientific studies funded by the
            NIH helped reveal that PTSD is a serious brain disorder with
            biological underpinnings. Healthcare practitioners today are
            better able than ever to help those who have suffered a
            traumatic event to cope, thanks to research over the past 20
            years. Yet much remains to be done, and this research must
            continue aggressively in light of returning veterans'
            healthcare needs in coming generations. NIH-funded studies on
            the brain chemicals and structures altered in PTSD offer
            particular hope for developing effective treatments. One
            approach is to target the corticotrophin-releasing factor
            (CRF), a brain chemical that plays a crucial role in
            coordinating the body's response to stress. And NIH-funded
            studies showed that drugs called selective serotonin reuptake
            inhibitors improved the memory of patients with PTSD and
            reduced shrinkage of brain tissue in the part of the brain
            involved in memory and emotion, helping PTSD patients better
            deal with traumatic memories.
      --Age-related Macular Degeneration.--As you grow older, you may some
            day notice your vision becoming blurry or distorted. Straight
            lines appear wavy, and it becomes more difficult to recognize
            familiar faces. These signs may point to age-related macular
            degeneration, or AMD, the leading cause of blindness and vision
            impairment among older Americans. AMD is a form of
            neurodegeneration that affects the light-sensitive nerve cells
            in the retina at the back of the eye. AMD causes nerve cells in
            the macula, the central region of the retina, to break down,
            and abnormal deposits accumulate beneath the retina. Many
            elderly people with AMD become socially isolated from friends
            and family and can no longer participate in the activities they
            once enjoyed. Thanks to work supported by NIH, scientists have
            made rapid advances in understanding AMD and are beginning to
            develop new treatments. Getting older remains the strongest
            risk factor, but scientists now know that AMD results from a
            complex interaction among genetic and environmental factors.
            For example, smoking increases the risk. One recent NIH study
            found that supplementing the diet with high levels of
            antioxidants and zinc reduced patients' risk of developing the
            advanced form of AMD disease by about 25 percent. The first
            drug to treat AMD was approved by the FDA in 2000. When this
            drug is activated by the application of laser light, it
            eliminates the faulty blood vessels underneath the retina and
            reduces further loss of vision. Doctors also may treat the
            disease directly with laser surgery, destroying new blood
            vessels and sealing leaks. Scientists have found important
            similarities between deposits that form in the eye in AMD and
            deposits in the brain in age-related neurodegenerative diseases
            such as Alzheimer's and Parkinson's. The deposits are found in
            some types of kidney disease as well. Because the effects of
            treatments are easier to visualize in the eye, studies of AMD
            may lead to improved treatment of these other diseases.
      --New Treatments From Nature's Poisons.--Neuroscientists have
            uncovered an unlikely source of new treatments for neurological
            disorders and diseases--the toxins and venoms of fish, snails,
            frogs, scorpions, and other creatures of land and sea. Brain
            researchers are finding that what makes these poisonous
            substances dangerous in the wild may also make them useful
            tools in the clinic. Already, they are helping to relieve
            chronic pain, and they may one day prove effective in treating
            brain cancer. One deadly venom--that of the giant yellow
            Israeli scorpion aptly nicknamed the ``deathstalker''--is being
            studied as a possible tool in the treatment of glioma, the most
            common type of brain tumor. Each year, about 22,000 Americans
            are diagnosed with this quickly spreading cancer, and many die
            within 12 months. Glioma cells spread throughout the brain,
            including into its narrowest spaces, with the help of special
            ion channels not found in healthy brain cells. A chemical in
            the deathstalker's venom, chlorotoxin, binds to these ion
            channels, an action that slows down the cancer's growth without
            harming nearby healthy cells. Other research suggests that
            chlorotoxin may be able to help kill gliomas and perhaps other
            cancerous tumors through a different mechanism--by shutting off
            their blood supply. A non-narcotic synthetic form of a
            poisonous compound found in the venom of cone snails is already
            helping to relieve chronic neuropathic pain in humans.
            Neuroscientists are currently investigating whether other
            chemicals in cone snail venom might help block the surge of
            electrical brain activity that triggers epileptic seizures.
        The above success stories required a close working collaboration
    between the basic researcher discovering new knowledge and the
    clinical-physician researcher translating those discoveries into new
    and better treatments. Much other research in neuroscience is dedicated
    to understanding basic phenomena, which, although motivated by clinical
    problems, are not yet at the stage where they can be translated into
    cures. For example, patients with lesions in the parietal lobe, a part
    of the cerebral cortex, are devastated by deficits in visual attention
    and spatial perception. NIH-supported research in my own laboratory has
    illuminated much of the signal processing by which the parietal lobe
    enables subjects to locate objects in space and attend to them. We now
    understand why patients with parietal lesions behave as they do;
    helping them is the next step. Other groups in the Mahoney-Keck Center
    at Columbia University are doing NIH-supported research into the basic
    mechanisms of how subjects assign value to objects in the world, and
    make choices based on that value. A clinically relevant example of
    these processes is the question of why a drug addict assigns high value
    to drugs and then decides to acquire them. This research will
    illuminate the neurobiology of processes like drug-seeking, and may
    lead to better treatment,

                                   CONCLUSION

        The field of neuroscience research holds great potential for
    addressing the numerous neurological illnesses that strike more than 50
    million Americans annually. As noted by my institution's (Columbia
    University) Mind, Brain and Behavior Initiative: ``In the 20th century,
    scientists discovered a great deal about the brain. They discovered
    what happens to individual neurons when memories are made and created
    powerful tools to image brain function. But while they made great
    strides toward understanding molecules, cells, and brain circuitry,
    scientists continue to unearth how these circuits come together in
    systems to record memories, illuminate sight and produce language. We
    have entered an era in which knowledge of nerve cell function has
    brought us to the threshold of a more profound understanding of
    behavior and of the mysteries of the human mind. Many believe that the
    next level of understanding will come from analyses not of single cells
    but of ensembles of neurons whose concerted actions must underlie the
    complexity of human behavior and thought. Neural circuits must, in some
    way, account for high-level functions such as memory, self-awareness,
    language, joy, depression, and anger. Taking this research to the next
    level through collaborations with the social sciences will illuminate
    and identify the role of social interactions in normal and abnormal
    brain function.'' However, this can only be accomplished by a
    consistent and strong funding source.
        An NIH appropriation of $35 billion for fiscal year 2011 is
    required to take this research to the next level in order to improve
    the health of Americans and to sustain the Nation's global
    competitiveness. Additionally, the new research capacity must be
    sustained to realize the scientific outcomes initiated by the Recovery
    Act dollars and to ensure the next generations of scientists will have
    opportunities in research. A strong scientific investment not only
    produces ground breaking medical treatments and discoveries; it
    supports national economic recovery, by creating thousands of jobs and
    forming the foundation for a stronger national economy based on
    technology and innovation.
        Thank you for the opportunity to submit this testimony.
                                     ______

       Prepared Statement of The Society for Healthcare Epidemiology of
                                    America

        The Society for Healthcare Epidemiology of America (SHEA)
    appreciates this opportunity to express its support for Federal efforts
    to prevent and reduce healthcare-associated infections. SHEA was
    founded in 1980 to advance the application of the science of healthcare
    epidemiology. The Society works to achieve the highest quality of
    patient care and healthcare personnel safety in all healthcare 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 diseases 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 and the Federal Healthcare Infection Practices
    Advisory Committee, and the Council of State and Territorial
    Epidemiologists (CSTE) 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. In 2008, SHEA
    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 Society also contributes expert
    scientific advice to quality improvement organizations such as the
    Institute for Healthcare Improvement, the National Quality Forum, and
    State-based task forces focused on infection prevention and public
    reporting issues.
        SHEA applauds the Congress for its support of HAI prevention and
    reduction activities through the American Recovery and Reinvestment Act
    (ARRA) in 2009. SHEA continues to collaborate with the Department of
    Health and Human Services (HHS) and the CDC to translate agency goals
    and objectives for HAI funds into actions at the bedside that can
    achieve meaningful reductions in preventable HAIs. However, there is a
    critical need for ongoing congressional support of a national
    prevention strategy to address a problem estimated by CDC to be one of
    the top ten causes of death in the Nation and one that poses a
    significant economic burden on the Nation's healthcare system.
    CDC
        The CDC plays a critical role in public health protection through
    its health promotion, prevention, preparedness, and research
    activities. As you consider fiscal year 2011 funding levels for the
    CDC, SHEA urges your support of at least $8.8 billion for CDC's ``core
    programs'' 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. CDC's leadership was
    especially critical in efforts to provide support and guidance to State
    and local health departments as well as the public in its response to
    the 2009 H1N1 influenza virus. 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, improving the
    public's health, and providing much-needed unbiased education on HAIs
    and their prevention.
        SHEA is particularly concerned about CDC's Infectious Diseases
    program budget, which supports critical management and coordination
    functions for infectious diseases research, policy development, and
    intervention programs including related specific epidemiology and
    laboratory activities. SHEA recommends an fiscal year 2011 funding
    level of $2.3 billion for CDC's Infectious Diseases programs.
        Within the Emerging and Zoonotic Infectious Disease programs'
    proposed budget, the agency's Antimicrobial Resistance budget would be
    cut dramatically by $8.6 million, or just more than 50 percent. This
    vital program is necessary to help combat the rising crisis of drug
    resistance, one of the most pressing problems and greatest challenges
    that healthcare providers will confront during the coming decade. As
    bacteria and other micro-organisms are becoming more resistant to
    antimicrobials, our current therapeutic options are dwindling and
    research and development of new antibiotics is lagging. For the first
    time since the discovery and introduction of penicillin in the 1940s,
    we are dangerously close to a return to the pre-antibiotic era.
        Antimicrobial resistance is a very real problem that extends to
    every segment of the healthcare community. Yet the President's fiscal
    year 2011 budget would allow only 20 State/local health departments and
    healthcare systems to be funded for surveillance, prevention, and
    control of antimicrobial resistance, down from 48 this past year. It
    would also eliminate all grants to States for the successful Get Smart
    in the Community program to combat improper uses of antibiotics. These
    cuts would be devastating at a time when we need to be fully committed
    to the goals of antimicrobial stewardship, to the research needed to
    define the most effective interventions and to educating the next
    generation of stewards.
        CDC's antimicrobial resistance activities including State-based and
    local surveillance and educational initiatives are so critical to
    protecting Americans from serious and life-threatening infections that
    SHEA urges you to double funding for CDC's antimicrobial resistance
    activities to at least $40 million in fiscal year 2011.
        SHEA strongly supports the proposed fiscal year 2011 increase of
    $12.3 million in the Preparedness, Detection and Control of Infectious
    Diseases line item to allow for the expansion of the National
    Healthcare Safety Network from 2,500 to 5,000 hospitals. 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. It
    is an enormously important national resource and effective funding and
    support is essential to expand its implementation. The proposed
    increase will allow CDC to build on progress made with fiscal year 2009
    ARRA funds to leverage the NHSN and support the dissemination of HHS
    evidence-based practices within hospitals to reduce these infections
    and save lives. These funds are also intended to allow CDC to build the
    workforce capacity, laboratory facilities, and skills sets within State
    and local health departments to enhance the ability to detect and
    control emerging infectious diseases. It should be noted that this
    funding level is not sufficient to sustain the NHSN and State and local
    health department activities in this area.
        SHEA urges you to increase the funding for CDC's budget line for
    Emerging Infections by $25 million in fiscal year 2011. In fiscal year
    2010, $11.7 million of this budget line were allocated to the Division
    of Healthcare Quality and Promotion. The additional $25 million should
    be used to support State and local health department HAI surveillance
    and prevention activities and provide a means for sustaining and
    expanding the important HAI initiatives that have been started using
    ARRA funds. Given the condition of State economies, it is unlikely that
    State funding will be available and the benefits of most programs will
    be lost at the end of 2011 without continued Federal support. As we
    seek to strengthen our public health infrastructure and reorient our
    health system toward prevention and preparedness, a strong Federal role
    should be part of a comprehensive approach to reduce HAIs and costs in
    line with the goals of healthcare reform.
        On a related note, recognizing that currently 21 States mandate the
    use of NHSN for State public reporting and this number is expected to
    grow, immediate efforts should be made to enable interfaces between
    electronic health records (EHRs) and NHSN. In this way, additional
    burdens are not placed upon healthcare entities from either an
    infection prevention and control or information technology (IT)
    perspective as the desirability for national database integration
    proceeds.
        SHEA is pleased with the proposed establishment and funding ($10
    million) of a new workforce program, the Health Prevention Corps,
    within the CDC to enhance the capacity of the public health
    infrastructure to respond to current and emerging health threats. This
    program is intended to recruit new talent for State/local health
    departments with a focus on disciplines with known workforce shortages,
    such as epidemiology. This investment is very timely, as a recently
    released report from the CSTE documented a 10 percent decline in the
    number of State-based epidemiologists over the last 3 years, with a 40
    percent deficit in the overall number of epidemiologists needed for
    full capacity across the 50 States. Clearly, our ability to reduce and
    prevent HAIs is highly dependent upon a continued strong investment in
    hospital infrastructure and qualified personnel for infection
    prevention and control.
    National Institutes of Health (NIH)
        SHEA is very pleased that ARRA infused the NIH 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. It is critical that
    we maintain this momentum for medical research capacity. Accordingly,
    SHEA supports an overall funding level of $35 billion for NIH in fiscal
    year 2011.
        While SHEA is very pleased with the proposed major investment in
    Agency for Healthcare Research and Quality (AHRQ) for research focused
    on HAIs (discussed below), support for basic, translational, and
    epidemiological HAI research has not been a priority of the NIH.
    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 on funding for HIV/AIDS research, approximately $2 billion on
    cardiovascular disease research, about $664 million on obesity research
    and, by comparison, National Institute of Allergy and Infectious
    Diseases (NIAID) 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 2011 to ensure adequate support for the
    research foundation that holds the key to addressing the multifaceted
    challenges presented by HAIs.
    AHRQ
        SHEA strongly supports the proposed investment of $34 million by
    AHRQ in fiscal year 2011 to reduce and prevent HAIs. Funds made
    available through AHRQ (and CDC) 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 Health Research and
    Educational Trust projects (for example, Public Health Research
    Institute 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 thanks the subcommittee for this opportunity to share our
    priorities with respect to fiscal year 2011 funding for HHS, CDC, NIH,
    and AHRQ. SHEA is pleased to serve as a resource to the committee going
    forward on issues related to healthcare epidemiology.
                                     ______

     Prepared Statement of the Sexuality Information and Education Council
                              of the United States

        SIECUS, the Sexuality Information and Education Council of the
    United States, has served as a strong national voice for sexuality
    education, sexual health, and sexual rights for more than 45 years.
        SIECUS affirms that sexuality is a fundamental part of being human,
    one that is worthy of dignity and respect. We advocate for the right of
    all people to accurate information, comprehensive education about
    sexuality, and sexual health services. SIECUS works to create a world
    that ensures social justice and sexual rights.

       PRESIDENT'S TEEN PREGNANCY PREVENTION INITIATIVE AT THE OFFICE OF
                               ADOLESCENT HEALTH

        As an organization committed to the health and education of our
    Nation's young people, we urge the subcommittee to invest in programs
    that provide all of our Nation's youth with comprehensive, medically
    accurate, and age-appropriate sex education that helps them reduce
    their risk of unintended pregnancy, HIV, and other sexually transmitted
    infections (STIs), as well as teach them about healthy relationships
    and communication and decisionmaking skills so they can make
    responsible decisions and lead safe and healthy lives.
        For the first time in more than a decade, the Nation's teen
    pregnancy rate rose 3 percent in 2006. During this time, teens were
    receiving less information about contraception in schools and their use
    of contraceptives was declining. Moreover, while making up only one-
    quarter of the sexually active population, young people aged 15-24
    account for roughly one-half of the approximately 19 million new cases
    of sexually transmitted infections (STIs) each year. Those aged 13-24
    account for one-sixth of new HIV infections, the largest share of any
    age group.
        We are pleased that the President's fiscal year 2011 budget request
    once again included funding for more comprehensive and evidence-based
    approaches to sex education. However, by focusing the funding on teen
    pregnancy prevention, and not including the equally important health
    issues of STIs including HIV, the Administration has missed an
    opportunity to provide true, comprehensive sex education that promotes
    healthy behaviors and relationships for all young people, including
    lesbian, gay, bisexual, and transgender (LGBT) youth. We must
    strategically and systemically provide young people with all the
    information and services they need to make responsible decisions about
    their sexual health. Therefore, we request that the teen pregnancy
    prevention initiative be broadened to address STIs, including HIV, in
    addition to the prevention of unintended teen pregnancy.
        Most of the evidence-based programs that have been proven effective
    at reducing risk factors associated with unintended teenage pregnancy
    and STIs by delaying sexual activity and increasing contraceptive use
    emphasize abstinence as the safest choice and also discuss
    contraceptive use as a way to avoid pregnancy and STIs, including HIV.
    In light of the evidence and recognizing more than one-half of young
    people have had sexual intercourse by the age of 18 and are at risk of
    both unintended pregnancy and STIs, we request that the committee
    direct the Office of Adolescent Health to prioritize funds to programs
    that are more comprehensive in scope insofar as they encourage
    abstinence but also encourage young people to always use condoms or
    other contraceptives when they are sexually active.
        Leading public health and medical professional organizations--
    including the American Medical Association, the American Academy of
    Pediatrics, the Society of Adolescent Medicine, and the American
    Psychological Association--support a comprehensive approach to
    educating young people about sex. Focusing on more comprehensive
    approaches is both good policy and good politics. It is good policy
    because it is based on scientific considerations and takes into account
    the reality of teens' lives. In sharp contrast to abstinence-only-
    until-marriage programs, there is strong evidence that more
    comprehensive approaches do help young people both to withstand the
    pressures to have sex too soon and to have healthy, responsible, and
    mutually protective relationships when they do become sexually active.
    Importantly, the evidence is strong that sex education programs that
    promote abstinence as well as the use of condoms do not increase sexual
    behavior. Studies show that when teens are educated about condoms and
    have access to the method, levels of condom use at first intercourse
    increase while levels of sex stay the same.
        Moreover, the CDC's Task Force on Community Preventive Services
    recently reviewed Comprehensive Risk Reduction programs and found
    sufficient evidence to recommend their use and support a conclusion
    that Comprehensive Risk Reduction interventions can have a beneficial
    effect on public health. The recommendation is based on sufficient
    evidence of effectiveness in: reducing a number of self-reported risk
    behaviors, including (1) engagement in any sexual activity, (2)
    frequency of sexual activity, (3) number of partners, and (4) frequency
    of unprotected sexual activity; (5) increasing the self-reported use of
    protection against pregnancy and STIs; and (6) reducing the incidence
    of self-reported or clinically-documented sexually transmitted
    infections.
        In addition, the vast majority of parents want the Federal
    Government to fund programs that are medically accurate, age-
    appropriate, and educate youth about both abstinence and contraception.
    Nationwide polls show that 8 in 10 voters want young people to receive
    a comprehensive approach to sex education that includes teaching about
    both abstinence and contraception. Furthermore, according to the
    results of a 2005-2006 nationally representative survey of U.S. adults,
    published in the Archives of Pediatrics and Adolescent Medicine, there
    is far greater support for comprehensive sex education than for the
    abstinence-only approach, regardless of respondents' political leanings
    and frequency of attendance at religious services. Overall, 82 percent
    of those polled supported a comprehensive approach, and 68 percent
    favored instruction on how to use a condom; only 36 percent supported
    abstinence-only programs.
        In these tight budget times, we are pleased that the President's
    fiscal year 2011 budget increased funding for the new teen pregnancy
    prevention initiative by $19.2 million, for a total of $133.7 million.
    We urge the committee to fund the initiative at least at the
    President's requested level of $133.7 million. We are also pleased that
    the President's budget has once again included zero dedicated funding
    for failed abstinence-only-until-marriage programs, and we encourage
    the subcommittee not to include funding for these ineffective programs.
        Congress should continue to act in the best interest of young
    people by supporting public health and education policies that are
    comprehensive, rooted in the best science, and reflect mainstream
    values.

     HIV PREVENTION AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

        President Obama proposed an increase of $31 million for HIV
    prevention programs at the Centers for Disease Control and Prevention
    (CDC). While we are grateful for this proposed increase during such
    difficult economic times, this amount is far from what is needed to
    reduce the number of new infections in the United States, which still
    stands at more than 56,000 per year. State and local health departments
    and community-based organizations need increased resources to
    strengthen and expand outreach, education, HIV testing, and prevention
    programs targeting high-risk populations. The CDC believes that in
    order to adequately address the HIV epidemic in this Nation, an
    additional $878 million is needed over each of the next 5 years. We are
    requesting an increase of $878 million for a total of $1.6 billion for
    CDC HIV prevention activities in fiscal year 2011.
        With increased funding, other crucial prevention efforts can be
    augmented such as the delivery and evaluation of behavioral
    interventions, social marketing campaigns, surveillance, and other
    preventative education programs. Community based organizations and
    State and local health departments are all facing severe financial
    challenges. Through budget cuts, hiring freezes, layoffs, and
    furloughs, health departments across the Nation continue to curtail
    core public health functions including those that prevent the spread of
    HIV and other infectious diseases. Additional Federal resources are
    absolutely necessary if we are to reverse the increase of new
    infections. Investing in HIV prevention will result in billions of
    dollars in reduced healthcare costs in the future. Moreover, given the
    strong epidemiological link between HIV and other STDs, including high
    rates of co-infection among certain populations such as African
    Americans and men who have sex with men, an increased investment in STD
    programs (through the Division of STD Prevention) is an essential
    component of scaling up HIV prevention efforts. The cost of treating
    new cases of HIV each year that is attributable to Chlamydia,
    gonorrhea, syphilis, and genital herpes is more than $1 billion per
    year.
        We also request an increase of $20 million, for a total of $60.2
    million, for the Division of Adolescent and School Health's HIV
    Prevention Education. Recent estimates suggest that while representing
    25 percent of the ever sexually active population, 15-24 year-olds
    acquire nearly one-half of all new STDs. Each year, one in four
    sexually active teenagers contracts a sexually transmitted disease. In
    addition, nearly 15 percent of the 56,000 annual new cases of HIV
    infections in the United States occurred in youth ages 13 through 24 in
    2006. This means that an average of one young person every hour of
    every day is infected with HIV in the United States. It is essential
    that we provide schools with the resources they require to build and
    strengthen their capacity to improve child and adolescent health.

      TITLE X FAMILY PLANNING PROGRAM AT THE OFFICE OF POPULATION AFFAIRS

        We request that funding for the title X family planning program be
    increased to $700 million over the next 5 years, beginning with an
    increase of $76.5 million in fiscal year 2011.
        Title X is a vital part of our Nation's healthcare infrastructure.
    The Institute of Medicine (IOM), in their recent review of the program,
    found title X to be a ``valuable program'' providing ``critical
    services'' to those in need, but also noted that the program is not
    currently receiving the funds needed to fulfill its mission. As the
    Administration and Congress work to reform our healthcare system, the
    President has stated that we must build on what works. Title X is a
    prime example of the type of successful programs that should be
    expanded. We appreciate the President's leadership in providing a $10
    million increase for title X in his fiscal year 2011 budget request.
    However, in spite of the program's critical role and proven
    effectiveness, funding for title X continues to fall well short of what
    is needed.
        Title X serves nearly 5 million low-income women and men at more
    than 4,500 health centers each year. Title X services help women and
    men plan the number and timing of their pregnancies, thereby helping to
    prevent nearly 1 million unintended pregnancies each year, nearly one-
    half of which would otherwise end in abortion. In addition to providing
    contraceptive services and supplies, title X health centers provide
    basic preventive health services, education, and counseling. For
    example, in 2007, title X centers provided 2.2 million Pap tests and
    2.4 million clinical breast exams. Not only do the services provided
    through title X promote public health, they also save tax dollars. For
    every public dollar invested in title X, $4.02 is saved in Medicaid-
    related costs alone.

                                   CONCLUSION

        We urge you to include in the Labor, Health and Human Services, and
    Education, and Related Agencies appropriations bill the strongest
    possible teen pregnancy prevention and sex education initiative that
    will meet the needs of all young people and help them achieve healthier
    and safer lives. We also urge you to adequately fund HIV prevention at
    the CDC and the title X family planning program so that the health
    goals of our Nation can be met.
                                     ______

         Prepared Statement of the Society for Maternal-Fetal Medicine

        Mr. Chairman and members of the subcommittee: The Society for
    Maternal-Fetal Medicine is pleased to have the opportunity to submit
    testimony in support of the fiscal year 2011 budget for the Eunice
    Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD). We are grateful for your strong and sustained
    commitment to the National Institutes of Health (NIH), in particular
    the NICHD. Through the programs of the NICHD, ground-breaking research
    advances have been made that have changed the practice of obstetrics.
        Established in 1977, the Society for Maternal-Fetal Medicine (SMFM)
    is dedicated to improving maternal and child outcomes; and raising the
    standards of prevention, diagnosis, and treatment of maternal and fetal
    disease.
        Maternal-fetal medicine specialists, also known as MFM specialists,
    perinatologists and high-risk pregnancy physicians, are highly trained
    obstetricians/gynecologists with advanced expertise in obstetric,
    medical, and surgical complications of pregnancy and their effects on
    the mother and fetus. The complex problems faced by these mothers may
    lead to death or problems, both short-term and life-long for both the
    mothers and their babies. Only through research can complications
    involving the mother or unborn fetus be understood, treated, prevented
    and eventually solved.
        The mission of NICHD is to ensure that every child is born healthy
    and that women suffer no harmful effects from reproductive processes.
    NICHD supports a blend of basic, clinical, translational, and
    multidisciplinary research studies that address a myriad of issues in
    pregnancy such as:
      --Preterm Birth.--Preterm birth (delivery before 37 weeks' gestation)
            is associated with increased risks of death in the immediate
            newborn period as well as in infancy, and can cause long-term
            complications including devastating disabilities. About 20
            percent of premature babies die within the first year of life,
            and although the survival rate is improving, many preterm
            babies have life-long disabilities, including cerebral palsy,
            mental retardation, respiratory problems, and hearing and
            vision impairment. Preterm birth occurs in nearly 13 percent of
            all deliveries in the United States, a higher rate than in
            other developed countries (5-9 percent). The total cost of
            preterm birth in the United States is $26 billion a year,
            according to a 2006 report of the Institute of Medicine.
      --Stillbirth.--Stillbirth defined as the death of a fetus at 20 or
            more weeks of gestation, complicated nearly 26,000 pregnancies
            in the United States in 2005. Considerable racial disparity
            exists--stillbirth is more than twice as common among African
            Americans than Caucasian women (11.1 versus 4.8 per 1,000).
            Other maternal risk factors for stillbirth include advanced
            age, obesity, and co-existing medical disorders such as
            diabetes or hypertension. The possible impact of environmental
            exposures on stillbirth risk remains unknown. Of known
            stillbirth causes, the most common are genetic abnormalities,
            alterations in the number or structure of the chromosomes,
            maternal infection, hemorrhage, and problems with the umbilical
            cord or placenta. However, the cause remains unknown in about
            one-half of all stillbirths.
      --Hypertensive Diseases in Pregnancy.--High blood pressure
            (hypertension) during pregnancy endangers the health of both
            the mother and the baby and is increasingly common as women
            delay pregnancy until they are older, and as they are more
            frequently overweight. Hypertension in pregnancy is the second
            leading cause of maternal death in the United States,
            accounting for 15 percent of all deaths. For the mother, it is
            associated with early delivery, increased need for labor
            induction because of pregnancy complications, stroke, pulmonary
            or heart failure, and death. The likelihood and severity of
            these complications increases as the severity of the
            hypertension increases, and if pre-eclampsia develops. Pre-
            eclampsia is characterized by high blood pressure and the
            presence of protein in the urine. Its cause, or causes, remains
            one of the greatest mysteries in obstetrics and is a major
            cause of maternal, fetal, and neonatal mortality worldwide.
      --Pregestational and Gestational Diabetes.--The hormonal changes of
            pregnancy can seriously worsen pre-existing diabetes and often
            bring about a diabetic state (gestational diabetes) in
            predisposed women. Whether diabetes mellitus existed before
            conception or gestational diabetes develops during pregnancy,
            maternal glucose intolerance can have significant medical
            consequences for both mother and baby. Poorly controlled
            diabetes is associated with miscarriage, congenital
            malformations, abnormal fetal growth, stillbirth, obstructed
            labor, increased cesarean delivery, and neonatal complications.
            Up to 200,000 pregnancies are affected by gestational diabetes
            each year.
        Great strides are being made through NICHD-supported research to
    address the complex situations faced by mothers and their babies. One
    of the most successful approaches for testing research questions
    related to preterm birth is the NICHD research networks, which allow
    researchers from across the country to coordinate their work and share
    data. The networks deal with different aspects of the problem of
    preterm birth and its consequence. For example:
      --Maternal-Fetal Medicine Units Network.--To achieve a greater
            understanding and pursue development of effective treatments
            for the prevention of preterm births, low birth weight infants
            and medical complications during pregnancy, in 1986 the NICHD
            established the Maternal-Fetal Medicine Units Network (MFMU).
            The MFMU Network has changed obstetrical practice by
            identifying new effective therapies and putting an end to
            practices that are not useful. It is the only national research
            infrastructure capable of performing the much needed large
            trials that provide the evidence on which sound medical
            practice is based. The MFMU Network is also the ideal vehicle
            to collaborate with other NIH networks, as well as
            international networks in order to improve global health. Since
            its inception, the Network has made several exciting scientific
            advancements and has been able to rapidly turn laboratory and
            clinical research into diagnostic examinations and treatment
            procedures that directly benefit those affected.
        --A major advance in the prevention of preterm birth has been the
                use of progesterone in the second and third trimesters,
                which resulted in a substantial reduction in the rate of
                preterm delivery among women who had a previous preterm
                birth and also reduced the risk of newborn complications.
                The annual savings of preventing recurrent preterm delivery
                by progesterone treatment in the United States has been
                estimated at more than $2 billion. Research into
                progesterone use in women with other risk factors is
                continuing. So far studies have shown that progesterone
                treatment is not effective in twin or triplet pregnancies,
                but it may reduce the rate of preterm birth in women with a
                short cervix. If effective for this indication,
                progesterone treatment would be particularly helpful for
                identifying women at risk in their first pregnancy. Ongoing
                study is needed to identify the optimal populations for
                treatment and the best treatment regimens.
        --A significant development in clinical care, antenatal
                corticosteroid administration promotes fetal lung maturity.
                It is one of the most effective means of preventing newborn
                complications, including respiratory distress,
                intraventricular hemorrhage, and death, when preterm birth
                occurs. Though a single course of treatment is effective if
                given before preterm birth, the effect appears to decline
                over time if the pregnancy remains undelivered. Research
                over the past decade has shown that repeated doses of
                antenatal corticosteroids, either weekly or on alternate
                weeks, is associated with negative effects on fetal growth
                that could potentially outweigh their benefits. Current
                research is evaluating the potential benefits of a single
                ``rescue course'' of corticosteroids for undelivered women
                who have a second episode of threatened preterm delivery.
        --Large trials have suggested that magnesium sulfate treatment,
                given when preterm delivery is expected before 32-34 weeks,
                results in a reduction in cerebral palsy. Because cerebral
                palsy is the most prevalent chronic motor disability, with
                an estimated lifetime cost of nearly $1 million per
                individual, its prevention is of great significance to
                patients, their family and to society. While current
                evidence is encouraging, further study is needed to
                determine the optimal treatment regimen and which
                pregnancies would benefit most from this intervention.
        Though novel and important research areas have emerged to improve
    the outcomes of mothers and babies, there are still many challenges
    that face us:
      --Translation of Genomics and Proteomics into Preterm Birth and
            Stillbirth.--Preterm birth and stillbirth represent two of the
            most important complications of pregnancy. Prevention of
            preterm birth and stillbirth depends on identifying women at
            risk and understanding the mechanisms of disease. It is
            imperative that NICHD take advantage of high throughput
            technologies to understand the causes of preterm birth and
            stillbirth and support genomics, proteomics, and metabolomics
            studies focusing on prediction and prevention of preterm birth
            and stillbirth, as well as the use of existing biobanks. The
            promise of these new technologies is that a better
            understanding of the biologic processes involved in pregnancy
            and pregnancy complications will lead to improved prediction,
            prevention, and treatment strategies that will improve maternal
            and infant health.
      --Severe, Early Adverse Pregnancy Outcomes.--Women with severe, early
            adverse pregnancy outcome, such as multiple losses, demises,
            and severe pre-eclampsia, are at increased risk for long-term
            chronic health problems, including hypertension, stroke,
            diabetes, and obesity. Studies have shown that women who have
            had pre-eclampsia are more likely to develop chronic
            hypertension, to die from cardiovascular disease and to require
            cardiac surgery later in life. In addition, approximately 50
            percent of women with gestational diabetes will develop
            diabetes later in life. Pregnancy can be considered as a window
            to future health and the immediate postpregnancy period
            provides a unique opportunity for prevention of chronic
            diseases later in life. Studies to identify women at risk for
            long term morbidity, and to develop strategies to prevent long
            term adverse outcomes in these women are urgently needed.
      --Maternal Fetal Medicine Units (MFMU)Network.--Vigorous support of
            the MFMU Network is needed so that therapies and preventive
            strategies that have significant impact on the health of
            mothers and their babies will not be delayed. Until new options
            are created for identifying those at risk and developing cause
            specific interventions, preterm birth will remain one of the
            most pressing problems in obstetrics.
        As the subcommittee moves forward with deliberations on the fiscal
    year 2011 budget, we urge you to provide greater resources to NIH, and
    in particular to NICHD. Research is the cornerstone for improving our
    understanding of the physiology and pathophysiology of pregnancy, the
    interrelationship between the mother and fetus, the impact of medical
    conditions on pregnancy and the impact of medical diseases and
    pregnancy outcomes on the long term health of both mother and child.
    With your support, researchers can continue to peel away the layers of
    complex problems of pregnancy that have such devastating consequences.
        Recommendations.--The Society for Maternal Fetal Medicine
    recommends:
      --An appropriation of $35 billion for the NIH in fiscal year 2011.
      --A funding level of $1.5 billion for NICHD.
      --NICHD sustain the research investment in the MFMU Network to
            facilitate resolution of the myriad of problems that affect
            high-risk mothers and their fetuses.
      --NICHD support genomics, proteomics, and metabolomics studies
            focusing on prediction and prevention of preterm birth and
            stillbirth.
      --NICHD identify women at risk for long-term morbidity and develop
            strategies to prevent long-term adverse outcomes.
        Thank you for the opportunity to present our views.
                                     ______

         Prepared Statement of the Society for Public Health Education

        The Society for Public Health Education (SOPHE) is a professional
    health education organization founded in 1950 to promote the health of
    all people by stimulating research on the theory and practice of health
    behavior; translating sound science into practice; and supporting high-
    quality standards for professional preparation. SOPHE is the only
    independent professional organization devoted exclusively to health
    education and health promotion. SOPHE's 4,000 national and chapter
    members work daily to improve health outcomes and promote wellness in a
    variety of settings, including schools, universities, healthcare
    organizations, corporations, voluntary health agencies and Federal,
    State, and local government. There are currently 20 SOPHE chapters
    covering more than 30 States and regions across the country.
        SOPHE's broad membership enables us to advocate and understand the
    need for increased resources targeted at the most pressing public
    health issues. For the fiscal year 2011 funding cycle, SOPHE encourages
    the Labor, Health and Human Services, Education, and Related Agencies
    (Labor-HHS) Subcommittee to increase funding for public health programs
    that focus on preventing chronic disease and other illnesses;
    eliminating health disparities; and promoting the coordinated school
    health model. In particular, SOPHE would like to request the following
    fiscal year 2011 funding levels for Labor-HHS programs:
      --$969.85 million for the National Center for Chronic Disease
            Prevention and Health Promotion;
      --$50 million for the Centers for Diseases Control and Prevention
            (CDC) and CDC Racial and Ethnic Approaches to Community Health
            (REACH U.S.) program;
      --$77.64 million for CDC Division of Adolescent and School Health,
            $33.9 million of which shall be specifically appropriated for
            the coordinated school health program; and
      --$30 million for the CDC Healthy Communities Program.
        SOPHE gratefully acknowledges the strong bipartisan support that
    the Senate Labor-HHS Subcommittee has provided to the CDC in recent
    years, including the funding dedicated to the Prevention and Wellness
    Fund in the American Recovery and Reinvestment Act of 2009. The field
    of health education and health promotion, which is some 100 years old,
    uses sound science to plan, implement, and evaluate interventions that
    enable individuals, groups, and communities to achieve personal,
    environmental, and population health. There is a robust, scientific
    evidence-base documenting not only that various health education
    interventions work but that they are also cost-effective. These
    principles serve as the basis for our support for the programs outlined
    below.
    Preventing Chronic Disease
        The data are clear: chronic diseases are the Nation's leading
    causes of morbidity and mortality and account for 75 percent of every
    dollar spent on healthcare in the United States. Collectively, they
    account for 70 percent of all deaths nationwide. Thus, it is highly
    likely that 3 of 4 persons living in the districts of the Labor-HHS
    Subcommittee members will develop a chronic condition requiring long-
    term and costly medical intervention in their lifetime. In 2008, heart
    disease and stroke were estimated to cost $448 billion in medical
    expenditures and lost productivity. In 2009, U.S. healthcare
    expenditures exceeded $7,200 for every man, woman, and child, primarily
    for diagnosis and treatment of chronic diseases.
        SOPHE is requesting a fiscal year 2011 funding level of $969.85
    million for CDC's National Center for Chronic Disease Prevention and
    Health Promotion (NCCDPHP) in order to adequately address the cost of
    chronic disease care and prevent it from further burdening our Nation's
    citizens and productivity. NCCDPHP is at the forefront of the U.S.
    efforts to prevent and control chronic diseases. The Center was
    substantially cut in 2006, and then has essentially been level-funded
    and has decreasing resources due to across the board rescissions--while
    chronic disease rates have continued to soar.
        Studies show that spending as little as $10 per person on proven
    preventive interventions could save the country more than $16 billion
    in just 5 years. The public overwhelmingly supports increased funding
    for disease prevention and health promotion programs. Small investments
    now in community-led, innovative programs will help to increase our
    Nation's productivity and performance in the global market; decrease
    rates of infant mortality, deaths due to cancer, cardiovascular
    disease, diabetes, and HIV/AIDS, and; increase immunization rates.
        SOPHE is requesting a fiscal year 2011 funding level of $30 million
    for CDC's Healthy Communities Program to advance policy and
    environmental change strategies in support of healthy eating, active
    living, and chronic disease and obesity prevention. Through the Healthy
    Communities Program, CDC collaborates with local and State health and
    park departments, national organizations with extensive community
    outreach, and community leaders to prevent chronic disease. Among the
    many successes of the program since its inception are restoring
    physical education to the school day; requiring physical activity and
    healthy snacks in child care sites; changing zoning requirements to
    include sidewalks to promote physical activity; and enhancing farmers
    markets and community gardens to for wider access to fruits and
    vegetables.
        Chronic disease prevention programs, like those delivered by
    NCCDPHP, are especially needed among our Nation's youth. In the last 20
    years, the percentage of overweight youth has more than doubled, and
    for the first time in two centuries, children may have a shorter life
    expectancy than their parents. Fifteen percent of children and
    adolescents are overweight and more than one-half of these children
    have at least one cardiovascular disease risk factor, such as elevated
    cholesterol or high blood pressure. Almost 80 percent of young people
    do not eat the recommended five servings of fruits and vegetables each
    day. Daily participation in high school physical education classes
    dropped from 42 percent in 1991 to 32 percent in 2001. Patterns of poor
    nutrition, lack of physical activity, and other behaviors such as
    alcohol and tobacco use established during youth often continue into
    adulthood and contribute markedly to costly, chronic conditions.
        CDC's Coordinated School Health Programs have been shown to be
    cost-effective in improving children's health, their behavior, and
    their academic success. This funding builds bridges between State
    education and public health departments to coordinate health education,
    nutritious meals, physical education, mental health counseling, health
    services, healthy school environments, health promotion of faculty, and
    parent and community involvement. Gallup polls show strong parental,
    teacher, and public support for school health education.
        SOPHE urges this subcommittee to support an appropriation of $33.9
    million in fiscal year 2010 for CDC's Division of Adolescent and School
    Health, Coordinated School Health Programs. In 2008, 43 States (plus
    five tribal governments and four territorial education agencies)
    applied for such funding; however, because of limited resources, only
    22 States and 1 tribal government were funded. A funding level of $33.9
    million would allow capacity building grants to an additional of up to
    17 States (from 23 to 40).
        Chronic diseases account also for the largest health gap among
    populations and increase health disparities among racial and ethnic
    minority groups. As the U.S. population becomes increasingly diverse,
    the Nation's health status will be heavily influenced by the morbidity
    of racial and ethnic minority communities. African Americans, Alaskan
    Natives, American Indians, Asian Americans, Hispanic Americans, and
    Pacific Islanders are more likely than whites to have poorer health and
    to die prematurely, especially from chronic conditions.
        SOPHE strongly urges an allocation of $50 million for CDC's REACH
    U.S. initiative to eliminate health disparities among urban and rural
    communities in the areas of cardiovascular disease, immunizations,
    breast and cervical cancer screening and management, diabetes, HIV
    infections/AIDS, and infant mortality. A funding level of $50 million
    would allow for the distribution of monies to support at least 10 2-
    year planning grants for communities to implement evidence- and
    practice-based approaches to reducing chronic disease rates.
        Launched in 2007, REACH U.S. is the next evolution of REACH 2010,
    which was developed by HHS and CDC to find ``out of the box''
    community-driven solutions to address health disparities. REACH U.S. is
    unique because it works across public and private sectors to conduct
    community based prevention research and demonstration projects that
    address social determinants of health. REACH U.S. programs are time-
    tested, community-led interventions that have proven success in
    decreasing health disparities. President Obama highlighted a need to
    address health disparities in his fiscal year 2011 budget blueprint,
    and with increased funding REACH U.S. programs can address his call to
    action.
        Thank you for this opportunity to present our views to this
    subcommittee. We look forward to working with you to improve the health
    and quality of life for all Americans.
                                     ______

         Prepared Statement of the Society for Women's Health Research

        On the behalf of the Society for Women's Health Research (SWHR) and
    the Women's Health Research Coalition (WHRC), we are pleased to submit
    the following testimony in support of Federal funding of biomedical
    research, and specifically women's health research.
        SWHR, a national nonprofit organization based in Washington DC, is
    widely recognized as the thought leader in research on sex differences
    and is dedicated to improving women's health through advocacy,
    education, and research. SWHR was founded in 1990 by a group of
    physicians, medical researchers, and health advocates who wanted to
    bring attention to the myriad of diseases and conditions that affect
    women uniquely.
        In 1999, the WHRC was established by SWHR to give a voice to
    scientists and researchers from across the country that are committed
    to improving women's health research. WHRC now has more than 650
    members, including leaders within the scientific community and medical
    researchers from many of the country's leading universities and medical
    centers, as well as leading voluntary health associations, and
    pharmaceutical and biotechnology companies.
        SWHR and WHRC are committed to advancing the health of women
    through the discovery of new, targeted scientific knowledge. We believe
    that sustained funding for biomedical and women's health research
    programs conducted and supported across the Federal agencies is
    absolutely essential if we are to meet the health needs of women, and
    men, and advance the Nation's research capability.
        In this testimony we address the clinical successes and financial
    hardships of five key agencies and subgroups doing the important work
    of sex-based research: National Institutes of Health (NIH), NIH's
    Office of Research on Women's Health (ORWH), Health and Human Services'
    Office of Women's Health (HHS), the Centers for Disease Control and
    Prevention (CDC), and the Agency for Healthcare and Research Quality
    (AHRQ). If America wants to remain a leader in healthcare advancement,
    if we are serious about the advancement of personalized medicine, if we
    are ready to stop wasting healthcare dollars on inappropriate
    treatments or the costs that come with guessing versus knowing-then we
    implore Congress to supply these agencies with the tools needed to
    accomplish these goals.
    National Institutes of Health
        Past congressional investment and support for NIH has positioned
    the United States as 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. The 111th
    Congress saw the importance of increasing funds to NIH in the 2009
    American Recovery and Reinvestment Act (ARRA). This funding is having
    an enormous impact on research and research facilities throughout the
    United States, creating new jobs, new innovations and improved
    technologies. However, the U.S.'s position as world leaders in
    biomedical research is threatened by a budget that does not continue to
    provide significant funding to NIH. Flat-lining NIH funding, or worse,
    cutting funds and not keeping up with inflation, threatens the
    developments started by ARRA, and puts the innovative research
    practices and reputation that America is known for in jeopardy.
        When faced with budget cuts, NIH has shown that it is left with no
    other option but to reduce the number of grants it is able to fund.
    When not including the one-time ARRA infusion of funds, the number of
    new grants funded by NIH had dropped steadily with budgets growing at
    less than that of inflation since fiscal year 2003. A shrinking pool of
    available grants has a significant impact on scientists who depend upon
    NIH support to cover both salaries and laboratory expenses to conduct
    high-quality biomedical research, putting both medical advancement and
    job creation at risk. Failure to obtain a grant decreases publishing of
    new finds and decreases the number of scientists gaining experience in
    research, both reducing a scientist's likelihood of achieving tenure in
    a university setting. New and less established researchers are forced
    to consider other careers, the end result being the loss in academia of
    the skilled bench scientists and researchers so desperately needed to
    sustain America's cutting edge in biomedical research.
        SWHR recommends Congress to set a laudable goal of reaching $40
    billion in NIH funding in the next 3 years. To meet this goal, SWHR
    urges you to exceed the administration's fiscal year 2011 request of a
    $1 billion increase and to allocate an additional $3 billion in funding
    for the NIH in fiscal year 2011, resulting in a total research budget
    of $34 billion.
        In addition, SWHR requests that Congress strongly encourage the NIH
    to utilize ARRA funding as well as appropriated dollars to ensure that
    women's health research receives resources sufficient to meet the
    health needs of all women. SWHR further recommends that NIH, with the
    funds provided, report sex differences in all research findings. With
    the tools the NIH already has available, it should seek to expand its
    inclusion of women in basic, clinical and medical research to phase I,
    II, and III studies. By currently only mandating sufficient female
    subjects in phase III, science misses out on the chance to look for
    variability by sex in the early phases of research, where scientists
    look at treatment safety and determine safe dose levels for new
    medications. By raising the bar, NIH can continue to serve as a role
    model for industry research, as well as other nations. Only by gaining
    more information on how therapies work in women will medicine be able
    to advance more targeted and effective treatments for all patients, men
    and women alike.
        Only within the past decade have scientists begun to uncover
    significant biological and physiological differences between women and
    men, as it impacts health and medicine. Sex-based biology, the study of
    biological and physiological differences between women and men, 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. Medications can have different effects in
    woman and men, based on sex specific differences in absorption,
    distribution, metabolism, and elimination. It is imperative that
    research addressing these important differences be supported and
    encouraged. Congress clearly recognizes these important sex differences
    and NIH should as well.
    Office of Research on Women's Health
        The NIH's Office of Research on Women's Health (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 female biomedical scientists and engineers in both the NIH
    and external research 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). The BIRCWH program, created in 2000, 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. SCORs,
    established in 2003, are designed to increase the transfer of basic
    research findings into clinical practice by housing laboratory and
    clinical studies under one roof. 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. 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. Each SCOR
    program costs $1 million per year and results in unique research.
        Additionally, Advancing Novel Science in Women's Health Research
    (ANSWHR) was created by ORWH in 2007 to promote innovative new concepts
    and interdisciplinary research in women's health research and sex/
    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, 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.
        In order for ORWH's programs and research grants to continue to
    expand and thrive, Congress must direct that NIH continue its support
    of ORWH and provide it with $2 million dollar budget increase, bringing
    its fiscal year 2011 total to $44.9 million.
    Health and Human Services' (HHS) Office of Women's Health (OWH)
        The HHS 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. Without OWH's actions, the task of translating
    research into practice would and will be only more difficult and
    delayed.
        Under HHS, several agencies have Federal offices specific to
    women's health. Agencies currently with offices, advisors, or
    coordinators for women's health or women's health research include the
    Food and Drug Administration, Centers for Disease Control and
    Prevention, Agency for Healthcare Quality and Research, Indian Health
    Service, Substance Abuse and Mental Health Services Administration,
    Health Resources and Services Administration, and Centers for Medicare
    and Medicaid Services. It is imperative that these offices are funded
    at levels adequate for them to perform their assigned missions, and are
    sustainable so as to support needed changes in the long term. We ask
    that the Committee Report reflect Congress's supports of the permanent
    existence of these various Federal women's health offices, recommending
    that they are appropriately funded on a permanent basis to ensure that
    these programs can continue and be strengthened in the coming fiscal
    year.
        It is only through continued and increased funding that the OWH
    will be able to achieve its goals. The budget for fiscal year 2010, as
    in recent years, flatlined OWH budget at $33.7 million. This was, 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, a total $35.7 million
    requested for fiscal year 2011.
    Centers for Disease Control and Prevention (CDC)
        SWHR supports the national and international work of the CDC, and
    especially the work of CDC's OWH. While aware of unavoidable cuts in
    many sectors of the fiscal year 2011 budget, SWHR is concerned that the
    proposed CDC budget cuts and project eliminations jeopardize a number
    of programs that benefit women, leaving them with even fewer options
    for sound clinical information. Research and clinical medicine are
    still catching up from decades of a male-centric focus, and when
    diseases strike women, there is a paucity of basic knowledge on how
    diseases affect female biology, a lack of drugs that have been
    adequately tested in women, and now even fewer options for information
    through the many educational outreach programs of the CDC.
        Cutting funding for programs on blood disorders, specifically for
    von Willebrand's disease, which has disproportionate impact on women,
    ending awareness campaigns on gynecological cancers funded by Johanna's
    Law, and eliminating specific funds dedicated to projects on
    Inflammatory Bowel Disease and Interstitial Cystitis (IC) will all
    result in women losing an advocate and a partner in advancing women's
    health. The proposed cuts to IC programs, in particular, equate to a
    loss of approximately half of its budget. These reductions translate to
    more than just a significant cut in total CDC budget. They create
    losses in jobs and in advocacy efforts led by patients suffering from
    these diseases, particularly IC, and their advocacy organizations,
    eliminating important education toward diagnosis and treatment. SWHR
    hopes that there will be serious consideration of the impact
    eliminating these programs will have on women, and men, who suffer
    these diseases, and encourages reviewing alternate sources of funding
    as a means to continue these important programs. The total savings
    realized by eliminating these programs is less than one half of 1
    percent of the total programmatic resources budget for the CDC, and
    their elimination will have ramifications on patients and providers, as
    well as incalculable effects on advocacy groups, jobs, and information
    campaigns.
    Agency for Healthcare and Research Quality (AHRQ)
        The Agency for Healthcare Research and Quality'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. Through AHRQ's research projects, lives have
    been saved. For example, it was AHRQ who first discovered that 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, including funds from
    ARRA, are moving AHRQ in the right direction. However, more core
    funding is needed to help AHRQ continue doing the research that helps
    patients and doctors make better medical decisions.
        AHRQ's budget for fiscal year 2009 was $372 million, $397 million
    for fiscal year 2010. Such modest annual increases will not offer
    results that improve decisionmaking by doctors and patients for
    improved health outcomes. 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 the administration's proposed
    $611 million for fiscal year 2011, an increase of $214 million more
    than the fiscal year 2010 level. The lion's share of this increase will
    appropriately focus on patient-centered health research. This will
    ensure that adequate resources are available for high-priority
    research, including women's healthcare, sex and gender-based analyses,
    and health disparities-information that can help to better personalize
    treatments and improve outcomes for female and male patients
    nationwide.
    Summary of Recommendations
      --NIH fiscal year 2011--Additional $3 billion funding, $34 billion
            total. Increased focus on women's health research. Inclusion of
            women in all phases of NIH research.
      --OWHR fiscal year 2011--Additional $2 million funding, $44.9 million
            total.
      --HHS fiscal year 2011--Permanent funding of Federal women's health
            offices throughout HHS. Additional $2 million for OWH, $35.7
            million total.
      --CDC fiscal year 2011--Restored or alternate funding for 4 select
            projects.
      --AHRQ fiscal year 2011--Match the administration's proposed budget
            of $611 million.
        In conclusion, SWHR and the WHRC would like to thank the Chair 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.
        As you craft the fiscal year 2011 Labor, Health and Human Services,
    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. Moreover, as you work with the Department of
    Health and Human Services to allocate funding from the Prevention and
    Public Health Fund, I urge you to use this funding to support the long-
    term transformation of the Nation's public health system.
    Community Prevention
        The United States spends more than any other Nation in the world on
    healthcare costs but lags behind other nations in certain indicators of
    health. To improve health across the country, we must transform
    communities to remove barriers to healthy lifestyles and ensure that
    Americans have access to healthy environments, nutritious foods and
    venues for physical activity. TFAH was pleased with the unprecedented
    investment that was made in community prevention via the American
    Recovery and Reinvestment Act (ARRA). Through its Communities Putting
    Prevention to Work Initiative, we'll begin to sow the seeds of
    transformation. In addition, programs at the CDC, in particular Healthy
    Communities and Racial and Ethnic Approaches to Community Health Across
    the U.S. (REACH-U.S.), prioritize the health of communities and support
    innovative approaches to addressing disparities and improving health.
    In fiscal year 2011, TFAH supports a total of $52 million for the
    Healthy Communities Program and $60 million for the REACH program to
    expand these successful programs to additional communities.
    School Health
        More than 23 million children in the United States are overweight
    or obese. To improve their health, we must reach them where they spend
    a great deal of time, and that includes schools. The Division of
    Adolescent and School Health's (DASH) Coordinated School Health Program
    provides funding to 22 States and one tribal government to strengthen
    the ability of State and local education agencies to address critical
    health issues, including obesity, asthma, tobacco use, HIV, STDs, and
    teen pregnancy, by building the capacity of funded partners to support
    science-based, cost-effective health programming. The President's
    fiscal year 2011 budget proposes to increase funding for DASH by $3.875
    million. We strongly support an increase for DASH's School Health
    Program and hope that at a minimum, the program will receive an
    additional $20 million in fiscal year 2011 to enable CDC to fund 15
    additional State education agencies and 25 additional local education
    agencies to reach more children and youth through quality school health
    programs.
    Pandemic Influenza
        The recent H1N1 flu outbreak demonstrated how rapidly a new strain
    of flu can emerge and spread around the world. H1N1 provided a real-
    world test that showed our strengths and vulnerabilities to respond to
    a major infectious disease outbreak. Prior pandemic preparedness
    investments resulted in the development of medical countermeasures that
    have been used in the H1N1 response. In addition, supplemental
    appropriations have been used for response activities, including
    vaccine production, distribution and administration; antiviral drugs;
    surveillance; communications and community mitigation; and laboratory
    support for virus detection. TFAH supports continuing funding for our
    annual pandemic flu preparedness activities in fiscal year 2011 at CDC
    ($156 million), the National Institutes of Health (NIH) ($35 million),
    the Food and Drug Administration (FDA) ($45 million) and the Office of
    the Secretary ($66 million) in order to strengthen our preparedness and
    response during any future outbreaks.
        TFAH also urges appropriators to explore means to incorporate
    pandemic preparedness funds for State and local health departments into
    annual funding streams, such as the CDC Public Health Emergency
    Preparedness and ASPR Hospital Preparedness Program cooperative
    agreements. There is no annually recurring funding to support State and
    local pandemic preparedness. Yet, pandemic and all-hazards preparedness
    requires sustainable lab capacity, modernized disease surveillance
    systems, a well-trained workforce, effective medical countermeasures
    delivery and administration, surge capacity, and continuous exercising
    and improvement of response plans.
        Another critical funding stream is the Biomedical Advanced Research
    and Development Authority (BARDA), which provides incentives and
    guidance for research and development of products to counter
    bioterrorism and pandemic flu. The President's budget proposes $476
    million for BARDA, with funding made available from current BioShield
    Special Reserve Fund balances. These funds would support research on
    countermeasures for biological threat agents, volatile nerve agents and
    radiological and nuclear threats. TFAH supports an increase in funding
    for BARDA and recommends that in fiscal year 2011, at least $500
    million is provided, with the acknowledgement that higher levels of
    funding must ultimately be allocated and sustained.
    Global Disease Detection (GDD)
        Despite remarkable breakthroughs in medical research and
    advancements in immunization and treatments, infectious diseases are
    undergoing a global resurgence that threatens health. 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. For
    fiscal year 2011, TFAH recommends $56 million for the GDD Program to
    enable CDC to increase the number of GDD centers and expand capacity at
    existing Centers. Funding would bring Thailand, Kenya, China and
    Guatemala to full capacity, support Egypt and Kazakhstan as basic
    centers and establish four additional developing centers.
    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. TFAH supports an
    additional $19.6 million for the Environmental Health Laboratory's
    biomonitoring capacity in fiscal year 2011 in order to fund 7 to 10
    grantees to conduct biomonitoring, increase the number of chemicals
    measured in CDC's National Report on Human Exposure to Environmental
    Chemicals, enable CDC to provide training and quality assurance for
    State laboratories awarded funds, and support the National Report on
    Biochemical Indicators of Diet and Nutrition.
        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. The Tracking Network helps build our capacity to respond to
    environmental health issues and helps document links between
    environmental hazards and chronic disease. The National Network
    launched in July of 2009. CDC now funds just 22 States and one city to
    build and implement State-based tracking networks that will feed into
    the National Network. One additional State will be funded due to the
    increase in the fiscal year 2010 appropriations for this program. In
    order for the Network to be truly national in scope, it must be
    expanded to all States. To build toward that vision, TFAH recommends
    providing $50 million for CDC's Environmental and Health Outcome
    Tracking Network to expand it to up to 13 additional grantees and
    support the continued development of a sustainable Network.
        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 fiscal
    year 2010 for the Climate Change Program at CDC. To enable CDC to fund
    20-25 States and localities for climate change needs assessment and
    planning, in addition to supporting other climate change preparedness
    activities, TFAH recommends at least $15,000,000 for CDC's Climate
    Change Program in fiscal year 2011. Ultimately, $50 million is needed
    to develop a credible and effective Climate Change Program.
    Public Health Workforce
        A final area of critical importance to our Nation's health is our
    public health workforce. The latest job loss survey by the National
    Association of County and City Health Officials (NACCHO) found that
    local health departments lost 8,000 jobs in the second half of 2009--
    compounding the loss of another 8,000 positions in the first half of
    the year. To address the workforce shortages in State and local health
    departments, the President's budget proposes a new workforce program,
    the Health Prevention Corps, which will recruit new talent into service
    for State and local health departments. The program will target
    disciplines with known shortages, such as epidemiology, environmental
    health and laboratory. Fiscal year 2011 funding would be used to
    establish a management plan for staffing and program administration,
    convene stakeholders to establish the program framework, and develop a
    curriculum for Corps members. TFAH supports the President's request of
    $10 million for the Health Prevention Corps in fiscal year 2011.
    The Prevention and Public Health Fund
        The Prevention and Public Health Fund, established by the Patient
    Protection and Affordable Care Act (Public Law 111-148), provides $500
    million in fiscal year 2010 and $750 million in fiscal year 2011 for
    programs authorized by the Public Health Service Act for prevention,
    wellness, and public health activities. This funding should be used to
    support the long-term transformation of the Nation's public health
    system. Investments from the Fund should be used in a manner that
    leverages change throughout the public health system--with a move away
    from a stove-piped, disease-by-disease approach to one that addresses
    the determinants of health in a cross-cutting manner.
        The overarching goal should be to optimize the health of everyone
    by creating healthier, more resilient communities, through policy,
    systems, organizational, and environmental change. Investments from the
    Fund should be science informed or evidence based, have measurable
    health outcomes and policy goals, promote innovation, focus on the
    determinants of health and health equity, and be held accountable. The
    National Prevention Strategy should become the basis for defining the
    goals of a transformed public health system, identifying gaps in the
    current system, and how the Fund can be used to help close these gaps.
    Expenditure of Initial Funds
        As the National Prevention Strategy is developed over the next
    year, expenditures under the Fund for fiscal year 2010 and fiscal year
    2011 should be consistent with the following categories of expenditure,
    which were included in the House-passed bill. These include:
      --Community Prevention.--A focus on community prevention is the
            centerpiece of a transformed public health system. The focus
            should reflect cross-cutting approaches to reducing the risks
            that affect health and safety. In addition to chronic diseases,
            attention should be given to other critical health issues, such
            as injury and violence prevention, reproductive health,
            infectious diseases, emergency preparedness, mental health,
            birth defects and developmental disabilities, and environmental
            health. While State and local health departments must be
            central players in community prevention, grant funding is also
            needed to support the work of nongovernmental organizations.
      --Core Capacity (For Both Health Departments and Others Doing
            Community Prevention).--Health departments have varying levels
            of expertise and competency to design and manage community
            interventions that focus on policy, systems, organizational,
            and environmental change. All health departments should be
            supported in their efforts to expand the role of community
            prevention in addressing the health needs of their populations,
            but particular effort should be made to close the geographic
            gap in capacity to build healthier, safer, and more resilient
            communities. This can be done at least in part through the
            support of the accreditation process, which is focused on
            building these capacities and thresholds. Even with
            accreditation, we will need to provide funding to build a
            public health workforce able to serve in these accredited
            health departments.
      --Research, Development, and Dissemination of Best Practices.--There
            is a continuing need to expand the science base of prevention,
            with particular emphasis on translation into practice and data
            to do appropriate program evaluation. This would include
            ramping up the capacity of the task forces on community and
            clinical prevention, creating the research and technical
            support for innovation in community prevention, and
            establishing the newly authorized program in public health
            services and systems research, with a particular emphasis on
            data collection and analysis.
                                     ______

                  Prepared Statement of the 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 2011 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 many
    Americans.

                                    HIV/AIDS

        HIV/AIDS remains one of the world's worst health pandemics in
    history. According to the Centers for Disease Control and prevention
    (CDC), 583,298 people have died of AIDS in the United States. In 2008,
    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.
        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.
        We are keenly aware of budget constraints and competing interests
    for limited dollars. Unfortunately, despite the growing need, domestic
    HIV/AIDS programs have experienced only very minor increases in recent
    years. We are pleased that President Obama continues to focus on
    domestic HIV/AIDS programs and has proposed increases for prevention
    and treatment. We hope you will support the President's desire and
    increase funding for these important public health programs. Federal
    funding is particularly critical at this time since State and local
    budgets are being severely cut during this economic downturn. Many
    States and local governments have greatly cut their HIV prevention and
    HIV/AIDS care programs at the very same time demand for services are
    escalating.
        Below are The AIDS Institute's program requests and supporting
    explanation:
    Centers for Disease Control and Prevention--HIV Prevention and
            Surveillance

                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                     Amount
    ------------------------------------------------------------------------
    Fiscal year 2010.............................................        728
    Fiscal year 2011 community request...........................      1,606
    ------------------------------------------------------------------------

        New infections are particularly occurring in certain populations,
    including African-American men and women and men who have sex with men.
    In order to address the specific needs of these populations and the
    increased number of people infected, CDC is going to need additional
    funding. Currently, the United States spends only about 4 percent of
    its domestic HIV/AIDS spending on prevention.
        The AIDS Institute is extremely supportive of President Obama's
    budget request to ``begin a focused initiative to prevent HIV through
    holistic and integrated approached to protect the health of gay,
    bisexual, and other MSM.'' We congratulate the President for proposing
    additional funding and for focusing it on gay men, which represent a
    majority of HIV cases in the United States and is the only group in
    which HIV incidence is increasing.
        Unfortunately, the $31 million increase for fiscal year 2011
    requested by the President is far from what is needed to significantly
    reduce the number of new HIV infections. According to the CDC's
    professional judgment budget, an additional $878 million for each of
    the next 5 years is necessary to improve HIV prevention efforts and
    reduce HIV transmission in the United States. Therefore, The AIDS
    Institute supports an increase for CDC HIV prevention funding by $878
    million in fiscal year 2011.
        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.
        At a time when State and local HIV prevention budgets are being
    cut, just to keep at the current funding levels will require a level of
    resources greater than what has been proposed. The AIDS Institute is
    concerned about any effort that would actually reduce the level of HIV
    prevention dollars at the State level. That is why we are opposed to
    language requested by the administration that would allow States to
    move up to 10 percent of its CDC funding, including HIV funding, to
    address the top six leading causes of death.
    Ryan White HIV/AIDS Programs

                            [In millions of dollars]
    ------------------------------------------------------------------------
                                                                     Amount
    ------------------------------------------------------------------------
    Fiscal year 2010.............................................    2,290.9
    Fiscal year 2011 community request...........................    3,101.5
    ------------------------------------------------------------------------

        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 a million low-income,
    uninsured, and underinsured people each year. In fiscal year 2010, the
    Program received an increase of $53 million, or just 2.3 percent. This
    increase does not even cover the rate of inflation. 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 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.
      --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 State HIV/AIDS
            funding reductions totaling more than $170 million occurred in
            29 States during fiscal year 2009. The situation for this year
            and next will be even worse. Thirty-three States who
            participated in the survey anticipate a decrease in State
            funding this year.
      --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 $225.9 million, for a total
            of $905 million.
      --Part B base provides essential services including diagnostic, viral
            load testing and viral resistance monitoring and HIV care to
            all 50 States, the District of Columbia, Puerto Rico, and the
            territories. We are requesting a $55.9 million increase, for a
            total of $474.7 million.
      --The AIDS Drug Assistance Program (ADAP) provides life-saving HIV
            drug treatment to more than 150,000 people, the majority of
            whom are people of color (59 percent) and very poor (74 percent
            are at or below 200 percent of the Federal poverty level).
            Currently, ADAPs are experiencing unprecedented growth. The
            monthly growth of 1,271 clients is an increase of 80 percent
            from fiscal year 2008 when ADAPs experienced an average monthly
            growth of 706 clients. Due to a lack of funding, States have
            instituted waiting lists and have reduced the number of drugs
            on their formularies, reduced eligibility and capped
            enrollment. There are currently 859 people in 10 States on ADAP
            waiting lists. In order to address the ADAP funding crisis,
            which will grow even worse in fiscal year 2011, we are
            requesting an increase of $370.1 million for a total of
            $1,205.1 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 $131 million increase, for
            a total of $337.9 million.
      --Part D provides care to more than 84,000 women, children, youth,
            and families living with and affected by HIV/AIDS. We are
            requesting a $7 million increase, for a total of $84.8 million.
      --Part F includes the AIDS Education and Training Centers (AETCs)
            program and the Dental Reimbursement program. We are requesting
            a $15.2 million increase for the AETC program, for a total of
            $50 million, and a $5.4 million increase for the Dental
            Reimbursement program, for a total of $19 million.
        For fiscal year 2011, the President requested an increase of only
    $39.5 million, or just 1.7 percent, for the entire Ryan White Program
    and no increase for Parts A and D of the Program. The AIDS Institute
    urges the subcommittee to consider the growing needs of all Parts of
    the Ryan White Program and provide the necessary resources it requires
    to meet the needs of people living with HIV/AIDS in the United States.
    National Institutes of Health--AIDS Research

                            [In billions of dollars]
    ------------------------------------------------------------------------
                                                                     Amount
    ------------------------------------------------------------------------
    Fiscal year 2010.............................................        3.1
    Fiscal year 2011 community request...........................        3.5
    ------------------------------------------------------------------------

        The National Institutes Health (NIH) conducts research to better
    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. 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
        President Obama and Congress took steps toward implementing
    comprehensive sexual education in fiscal year 2010 by ending
    discretionary funded abstinence-only until marriage programs and
    creating the Teen Pregnancy Prevention Initiative. We urge the Congress
    to continue no funding for abstinence only education programs.
    Additionally, we believe the Teen Pregnancy Prevention Initiative
    should be expanded so that it addresses other aspects of sexual health,
    including HIV and STD prevention.
    Syringe Exchange Programs
        By eliminating the Federal funding ban on syringe exchange programs
    in fiscal year 2010, Congress allowed funding of a proven method to
    reduce the transmission of HIV and other infectious diseases. The AIDS
    Institute requests that you work to ensure that this ban is not
    reinstated.
    Minority AIDS Initiative
        The AIDS Institute supports increased funding for the Minority AIDS
    Initiative (MAI), which is funded by numerous Federal agencies. MAI
    funds services nationwide that address the disproportionate impact that
    HIV has on communities of color. We are requesting a $207.1 million
    increase across the MAI's programs, for a total of $610 million.

                                VIRAL HEPATITIS

        The Institute of Medicine (IOM) recently released a report
    ``Hepatitis and Liver Cancer: A National Strategy for Prevention and
    Control of Hepatitis B and C.'' It outlines a number of recommendations
    on how the incidence of Hepatitis B and C infections can be decreased.
    These recommendations include increased public awareness campaigns,
    heightened testing and vaccination programs, continued research, along
    with improved surveillance and other prevention programs.
        According to the IOM, 3.5-5.3 million people, or 1-2 percent of the
    U.S. population are living with chronic Hepatitis B or C. Because of
    their asymptomatic nature, the vast majority of infected people are
    unaware of their infection. There are an estimated 43,000 new acute
    Hepatitis B infections each year in the United States. The CDC
    estimates that 10 percent of people with Hepatitis B are co-infected
    with HIV and 25 percent of people with Hepatitis C are co-infected with
    HIV. Congress currently funds CDC's Viral Hepatitis Division at only
    $19.3 million. Given the huge impact that Hepatitis B and C have on the
    health of so many people, and the large treatment costs, The AIDS
    Institute requests an increase of $30.7 million, for a total of $50
    million.
        The AIDS Institute asks that you give great weight to our testimony
    as you deliberate over the fiscal year 2011 appropriation bill.
                                     ______

               Prepared Statement of the Tri-Council for Nursing

        The Tri-Council for Nursing, comprising the American Association of
    Colleges of Nursing, the American Nurses Association, the American
    Organization of Nurse Executives, and the National League for Nursing,
    respectfully requests $267.3 million (a 10 percent increase) for the
    Nursing Workforce Development programs authorized under title VIII of
    the Public Health Service Act (42 USC 296 et seq.) in fiscal year 2011.
        The Tri-Council is a long-standing alliance focused on leadership
    and excellence in the nursing profession. The Nation is currently in
    the twelfth year of the nurse and nurse faculty shortages, contributing
    to a workforce deficit that diminishes the quality of patient care in
    the United States. As the Nation looks towards reforming the healthcare
    system by focusing on expanding access, decreasing cost, and improving
    quality, a significant investment must be made in strengthening the
    nursing workforce.
        In fiscal year 2010, your subcommittee provided a considerable
    funding boost for title VIII that helped support the Loan Repayment and
    Scholarship program and Nurse Faculty Loan program. These increases
    will help bolster the pipeline of nurses and nurse faculty, which are
    so critical to reversing the nursing shortage. It is extremely
    important to maintain last year's funding level for these crucial
    programs in fiscal year 2011. The Tri-Council believes the 10 percent
    requested increase should be directed to the four title VIII programs
    that have not kept pace with inflation since fiscal year 2005. These
    programs include the Advanced Education Nursing, Nursing Workforce
    Diversity, Nurse Education, Practice, and Retention, and Comprehensive
    Geriatric Education programs, which help expand nursing school capacity
    and increase patient access to care. The 10 percent increase awarded to
    these programs in proportion to their fiscal year 2010 funding level
    would be a wise investment of Federal resources.
    four nursing workforce growth areas: critical title viii programs that

                               PROVIDE SOLUTIONS

    A Shortage of Providers Needed to Meet Increasing Healthcare Demands
        With healthcare access expanded through the newly passed reforms,
    more providers will be needed. According to the U.S. Bureau of Labor
    Statistics (BLS), nursing is the Nation's top profession in terms of
    projected job growth with more than 581,000 new nursing positions being
    created through 2018 (a 22 percent increase in the workforce).
    Moreover, healthcare professionals with knowledge and expertise in
    primary, transitional, and preventative care will be in great demand.
    Registered Nurses (RNs), Advanced Practice Registered Nurses (APRNs),
    and RNs with advanced education have the skills and are licensed to
    provide these vital services. The Advanced Education Nursing Grants and
    Traineeships help to educate the next generation of these providers in
    addition to the faculty who educate them.
        Advanced Education Nursing (AEN) Grants (section 811) support the
    preparation of RNs in master's and doctoral nursing programs. The AEN
    grants help to prepare our Nation's nurse practitioners, clinical nurse
    specialists, nurse midwives, nurse anesthetists, nurse educators, nurse
    administrators, public health nurses, and other nurse specialists
    requiring advanced education. In fiscal year 2008 (the most recent year
    for which data are available), these grants supported the education of
    5,649 students.
      --AEN Traineeships assist graduate nursing students by providing full
            or partial reimbursement for the costs of tuition, books,
            program fees, and reasonable living expenses. In fiscal year
            2008, this funding helped support 6,675 graduate nurses and
            APRNs.
      --Nurse Anesthetist Traineeships (NAT) support the education of
            students in nurse anesthetist programs. In some States,
            Certified Registered Nurse Anesthetists (CRNAs) are the sole
            anesthesia providers in almost 100 percent of rural hospitals.
            Much like the AEN Traineeships, the NAT provides full or
            partial support for the costs of tuition, books, program fees,
            and reasonable living expenses. In fiscal year 2008, the
            program supported 2,145 future CRNAs.
    Increasing Nursing Diversity to Improve Patient Care
        According to an April 2000 report prepared by the National Advisory
    Council on Nurse Education and Practice, a culturally diverse nursing
    workforce is essential to meeting the healthcare needs of the Nation's
    population. However, the initial findings from the 2008 National Sample
    Survey of Registered Nurses show that while RN graduates entering the
    profession represent greater cultural diversity, when compared to the
    U.S. population, the profession still does not represent the current
    demographics of this country. Nurses from racial and ethnic minorities
    underrepresented in nursing contribute significantly to the provision
    of healthcare services and are leaders in the development of models of
    care that address the unique needs of our Nation's populations. The
    Workforce Diversity Grants under title VIII help to ensure a nursing
    workforce is developed to meet the healthcare needs of all patients.
        Workforce Diversity Grants (section 821) prepare students from
    disadvantaged backgrounds to become nurses. This program awards grants
    and contract opportunities to schools of nursing, nurse-managed health
    centers, academic health centers, State or local governments, and
    nonprofit entities looking to increase access to nursing education for
    disadvantaged students, including racial and ethnic minorities
    underrepresented among RNs. In fiscal year 2008, the program supported
    11,638 students.
    Education, Practice, and Retention: Enhancing and Maintaining the
            Knowledge Base of Nursing
        Advances in healthcare technology, practice, and systems influence
    the way nurses deliver quality care. Like other health professions,
    nurses must continually expand their knowledge base to adapt to the
    changing healthcare environment. Higher learning and continued
    education for nurses are expected of all RNs as the profession strives
    for excellence in patient care. The Nurse Education, Practice, and
    Retention Grant program is designed to ensure RNs obtain additional
    knowledge in the discipline by expanding their entry-level education,
    improving their practice, and retaining seasoned clinicians in the
    profession.
        Nurse Education, Practice, and Retention Grants (section 831) help
    schools of nursing, academic health centers, nurse-managed health
    centers, State and local governments, and healthcare facilities
    strengthen programs that provide nursing education. The three priority
    areas under this program help to:
      --Expand the enrollment in baccalaureate nursing programs;
      --Develop and implement internship and residency programs to
            encourage and mentor, as well as for the development of
            specialties;
      --Provide education in new technologies, including distance learning
            methodologies;
      --Establish or expand nursing practice arrangements in
            noninstitutional settings to demonstrate methods to improve
            access to primary healthcare in medically underserved
            communities;
      --Provide care for underserved populations and other high-risk groups
            such as older adults, individuals with HIV/AIDS, individuals
            with substance use disorders, people who are homeless, and
            those who are victims of domestic violence;
      --Provide managed care, quality improvement, and other skills needed
            to practice in existing and emerging organized healthcare
            systems;
      --Develop cultural competencies among nurses;
      --Offer grants for career ladder programs to promote career
            advancement for nursing personnel and to assist individuals in
            obtaining education and training required to enter the nursing
            profession and advance within the profession; and
      --Provide grants that enhance patient care delivery systems and are
            directly related to nursing activities by enhancing
            collaboration and communication among nurses and other
            healthcare professionals, and promote nurse involvement in the
            organizational and clinical decisionmaking processes of a
            healthcare facility.
        In fiscal year 2008, the priority areas under this program
    supported 42,761 nurses and nursing students.
    Increased Nursing Care Needed for an Aging Population
        Today, more than at any other time in our Nation's history, nurses
    face an unprecedented challenge-caring for an aging population that is
    growing at an exponential rate. According to the U.S. Census Bureau,
    36.3 million Americans are older the age of 65, which represents 12
    percent of the total population. It has been projected that by 2050,
    86.5 million Americans will be older the age of 65. This represents a
    147 percent increase between the years 2000 and 2050.
        The National Center for Healthcare Statistics has reported that
    older adults account for 50 percent of hospital days, 60 percent of
    ambulatory adult primary care visits, 70 percent of all home care
    visits, and 85 percent of residents in nursing homes. Moreover, 63
    percent of newly licensed nurses report that older adults comprise a
    majority of their patient loads. Clearly, more RNs are needed with
    expertise in geriatric nursing. The Comprehensive Geriatric Education
    Grants help to educate the next generation of these practitioners.
        Comprehensive Geriatric Education Grants (section 855) are awarded
    to schools of nursing or healthcare facilities to better provide
    nursing services for older adults. These grants are used to educate RNs
    who will provide direct care to older Americans, develop and
    disseminate geriatric curriculum, prepare faculty members, and provide
    continuing education. In fiscal year 2008, this program supported 6,514
    nurses and nursing students.
        With increased funding, these four programs can help address many
    issues currently impacting the nursing shortage. Therefore, the Tri-
    Council respectfully request $267.3 million (a 10 percent increase) for
    the Nursing Workforce Development programs in fiscal year 2011.
                                     ______

                  Prepared Statement of The Endocrine Society

        The Endocrine Society is pleased to submit the following testimony
    regarding fiscal year 2011 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.
        Each year, the NIH funds thousands of research grants, facilitating
    the discovery of methods of prevention, treatment, and cure for
    debilitating diseases that negatively impact the health of the Nation's
    citizens and fuel rising healthcare costs. Nearly half of all Americans
    have a chronic medical condition, and these diseases now cause more
    than half of all deaths worldwide. Deaths attributed to chronic
    conditions could reach 36 million by 2015 if the trend continues
    unabated.
        Congress and President Obama recognized the contributions of NIH to
    the health of the Nation and the Nation's economy by awarding the
    agency more than $10 billion through the American Recovery and
    Reinvestment Act (ARRA). These funds supported more than 12,000 grants
    and created more than 50,000 jobs. ARRA funds have allowed the NIH to
    award grants, including those described in the bulleted list below,
    which will lead to breakthroughs in hundreds of disease areas,
    including those chronic diseases that result in the death of so many
    people each year.
      --A project is using information from a clinical trial in people with
            type 2 diabetes and heart disease to examine the association
            between fat cell hormones and CVD, including their potential
            usefulness in prognosis, monitoring effects of therapy, and
            identifying risk.
      --A project will conduct research in mice to develop a vehicle to
            deliver a specific gene that may prevent type 1 diabetes.
      --A grant to provide insights into the mechanisms by which diet and
            exercise reduce abdominal fatness and improve cardiovascular
            health in overweight and obese persons with type 2 diabetes.
            These mechanisms include systemic inflammation, insulin
            sensitivity, and aerobic and strength fitness.
      --Researchers will define how certain carbohydrate molecules affect
            hormone function, to better understand reproductive
            development, and development of breast and prostate cancer.
      --Scientists will assess how a specific gene helps trigger the
            development of stem cells into sperm, which could lead to new
            treatments for male infertility or new contraceptive targets.
      --A project will investigate the role of developmental exposure to
            Bisphenol A (BPA) on obesity and metabolic syndrome.
        Most of these grants would not have been funded through the regular
    grant approval process, and without the ARRA funds, the discoveries
    that are expected to result from these projects would never have a
    chance to be made. Furthermore, many of the scientists funded through
    these grants may never have received the funds necessary to start or
    continue their careers, including many first-time awardees. As the
    United States continues to lose its place as the world leader in
    innovation, we cannot miss out on opportunities to award bright young
    scientists and engage them in the research process.
        Unfortunately, the grants and jobs created will disappear at the
    end of fiscal year 2010 if Congress does not sustain the momentum
    created by the ARRA funds with a significant increase in the fiscal
    year 2011 budget. While it is not feasible to expect that the NIH
    budget can be increased in 1 year to a level that will sustain the
    12,000 grants awarded through the ARRA funds, Congress must do what it
    can to ensure that NIH receives steady, sustainable, predictable
    increases that avoid the boom and bust cycle that NIH experienced with
    the doubling of its budget, and now faces again with the end of the
    ARRA funds.
        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
    recommends that NIH receive $37 billion in fiscal year 2011 to prepare
    for the poststimulus era and ensure the steady and sustainable growth
    necessary to continue building on the advances made by scientists
    during the past decade.
                                     ______

           Prepared Statement of the Telehealth Leadership Initiative

        The Telehealth Leadership Initiative (TLI)--a nonprofit
    organization that represents the telehealth and e-health stakeholders
    before legislative, administrative, and judicial branches of local,
    State, and national governments and the entire telehealth community--
    appreciates the opportunity to submit written testimony to the Senate
    Labor, Health and Human Services, Education, and Related Agencies
    Appropriations Subcommittee. We respectfully request that the
    subcommittee maintain last year's funding levels and continue to
    provide $11.6 million for the Office for the Advancement of Telehealth
    (OAT), in the fiscal year 2011 Labor, Health and Human Services,
    Education, and Related Agencies appropriations bill. These resources
    will support access to quality healthcare services, through telehealth
    technologies, for remote, rural and underserved populations.

                              TELEHEALTH OVERVIEW

        Telehealth, also known as telemedicine, is the providing of
    healthcare, health information, and health education across a distance,
    using telecommunications technology, and specially adapted equipment.
    It allows physicians, nurses, and healthcare specialists to assess,
    diagnose and treat patients without requiring both individuals to be
    physically in the same location, regardless of whether that distance is
    across a street, across a city, across the State, or across continents.
        There are many applications for telehealth, such as:
      --Monitoring patients with chronic conditions or at-risk populations;
      --Medical care for home-bound patients or those in rural, remote, or
            frontier locations;
      --Mental telehealth for incarcerated populations;
      --Access to medical care in areas with provider shortages;
      --Access to healthcare services for those in correctional facilities;
            and
      --Availability of expert consultations via satellite for individuals
            on the battlefield, cruise ships, space stations, research
            stations, and other inaccessible locations.
        Telehealth has been used to successfully accomplish the following:
      --Prevent unnecessary delays in receiving treatment;
      --Reduce or eliminate travel expenses;
      --Reduce or eliminate the separation of families during difficult and
            emotional times;
      --Utilize the services of healthcare providers in locales where the
            supply of physicians may be adequate or at a surplus; and
      --Allow patients to spend less time in waiting rooms.
        Currently, telehealth is practiced in many settings, such as rural
    hospitals, school districts, home-health settings, nursing homes,
    cruise ships, on the battlefield, and even on NASA space missions.
    Telehealth is well-established in certain disciplines, such as
    radiology and dermatology, and is being expanded in other disciplines,
    for example, home telehealth, mental telehealth, ocular telehealth,
    teledermatology, telepathology, telerehabilitation. It is being
    utilized further for specific populations, including individuals who
    are incarcerated or live or are stationed in remote locations.

                                  OAT OVERVIEW

        The Office for the Advancement of Telehealth (OAT), which is a
    grant making agency at the Department of Health and Human Services, is
    responsible for promoting the use of telehealth technologies for
    healthcare delivery, education, and health information services.
    Through its programs, OAT helps bring access to care to those living in
    remote, rural and underserved populations.

                 REQUESTED FUNDING LEVELS FOR FISCAL YEAR 2011

        Over the years, telehealth has improved a patient's access to
    timely specialty care, reduced medical errors, and saved our healthcare
    system money. Last year, Congress funded telehealth initiatives at
    $11.6 million for fiscal year 2010. This year, the TLI urges the Senate
    to maintain the same funding level for fiscal year 2011.
        We feel strongly that an $11.6 million funding level for OAT is
    essential to ensuring that millions of Americans have access to quality
    healthcare services. Maintaining these funding levels will allow these
    programs to continue to work with and support communities, in their
    efforts to develop cost-effective uses of telehealth technologies.
        These initiatives, carried out through OAT, are especially valuable
    in a time when millions of Americans are struggling to access quality
    healthcare services.

                         CREDENTIALING AND PRIVILEGING

        In fiscal year 2010, the subcommittee expressed its concern about a
    process soon to be enforced by the Centers for Medicare and Medicaid
    Services that would require all telemedicine originating sites where
    the patient is located to credential and privilege all telemedicine
    practitioners. For many small hospitals receiving telemedicine
    services, this could mean credentialing and privileging tens, if not
    hundreds, of telemedicine practitioners. It is a cost and personnel
    burden that essentially would force the closure of many telemedicine
    programs throughout the country. It is the single greatest threat to
    the expansion of telemedicine.
        Since passage of the fiscal year 2010 appropriations, some positive
    developments have occurred. CMS has reached out to the telemedicine
    community and appears to be actively seeking a solution to the impact
    of this credentialing and privileging requirement. We urge the
    Committee to continue to exert it's oversight on this issue to ensure
    that CMS develops a workable policy that does not cripple the delivery
    of telehealth services, while at the same time protects patient safety,
    a goal that the telehealth community shares with CMS.

                                   CONCLUSION

        Thank you for you attention to this important healthcare matter. We
    know you face many challenges in choosing funding priorities, but we
    hope you will continue to keep telehealth a priority and maintain last
    year's funding levels of $11.6 million, in this year's fiscal year 2011
    appropriations' process. TLI appreciates the opportunity to share its
    views, and we thank you for your consideration of our request.
                                     ______

                 Prepared Statement of the NephCure Foundation

    One Family's Story
        Mr. Chairman 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 one
    of two filter diseases called Minimal Change Disease (MCD) 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 NCF has been very helpful to my family. They have provided us
    with educational information about NS, MCD, 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 NIH. 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-10-113).
        Mr. Chairman, on behalf of the thousands of people suffering from
    NS and FSGS and the NephCure Foundation (NCF), thank you for this
    opportunity to submit this testimony to the subcommittee and for your
    consideration of my request.
    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 along with the National
    Institutes of Health (NIH) to support the establishment of the
    Nephrotic Syndrome Rare Disease Clinical Research Network. This network
    is a new collaboration between research institutions, the NCF, and NIH
    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, including populations for clinical
    trials. 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 2007, is glomerular-disease specific.
    The announcement will utilize the R01 mechanism to award researchers
    funding. In February 2010 the PA was re-released for a further 3 years.
        We ask the subcommittee to encourage the ORDR to continue to
    support the Nephrotic Syndrome Rare Disease Clinical Research Network
    to expand FSGS research. We also ask the subcommittee to encourage
    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.
        It would be of great benefit for CDC to begin raising public
    awareness of the glomerular diseases in an attempt to diagnose patients
    earlier.
        We ask the subcommittee to encourage CDC to establish a glomerular
    disease education and awareness program aimed at both the general
    public and healthcare providers.
    Glomerular Disease Strikes Minority Populations
        Nephrologists tell us that glomerular disease strikes African
    Americans nearly 5 times more frequently than white Americans. No one
    knows why this is, but some studies have suggested that the MYH9 gene,
    which is 5 times more prevalent in African Americans, may be linked to
    susceptibility to FSGS. NIDDK will be sponsoring a conference on this
    issue on April 19-20, 2010.
        We ask that the NIH pay special attention to why this disease
    affects African Americans to such a large degree and often in a more
    severe manner. The 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 Panamian
    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.
        The Nephrotic Syndrome Rare Disease Clinical Research Network
    offers an excellent opportunity for NCMHD to collaborate with a wide
    variety of researchers and institutions to increase knowledge of NS/
    FSGS. The addition of NCMHD would add additional insight into the
    minority community, which is so disproportionately impacted by FSGS.
        We ask the subcommittee to encourage ORDR, NIDDK, and NCMHD to
    collaborate on research that studies the incidence and cause of this
    disease among minority populations. We also ask the subcommittee to
    urge NIDDK and the NCMHD undertake culturally appropriate efforts aimed
    at educating minority populations about glomerular disease.
                                     ______

                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 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.

                             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.

                             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.
        Unfortunately, support for scleroderma research at the National
    Institutes of Health over the past several years has been relatively
    flat funded at $20 million in fiscal year 2008, $21 million in fiscal
    year 2009, and an estimated $22 million in fiscal year 2010. This slow
    rate of increase is extremely frustrating to our patients who recognize
    biomedical research as their best hope for a better quality of life. It
    is also of great concern to our researchers who have promising ideas
    they would like to explore if resources were available.

                              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 (SSc)
        There are two major types of systemic sclerosis or 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
    half an 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 2011 appropriations recommendations
        An increase in funding for the National Institutes of Health (NIH)
    to $35 billion.
      --An increase for the National Institute of Arthritis and
            Musculoskeletal and Skin Diseases (NIAMS) concurrent with the
            overall increase to NIH.
      --Committee 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 United Tribes Technical College

        For 41 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. Unemployment among the Great Plains tribes,
    where most of our students are from, typically run at about 75 percent.
    We are governed by the five tribes located wholly or in part in North
    Dakota; we are not part of the North Dakota State college system and do
    not have a tax base or State-appropriated funds on which to rely. We
    have consistently had excellent retention and placement rates and are a
    fully accredited institution. Section 117 Perkins funds represent about
    half of our operating budget and provide for our core instructional
    programs. The request of the United Tribes Technical College Board is
    for the following authorized programs:
      --$10 million for base funding authorized under section 117 of the
            Carl Perkins Act (20 U.S.C. 2327). This is $1.8 million above
            the fiscal year 2010 level. These funds are shared via a
            formula by UTTC and Navajo Technical College.
      --$36 million as requested by the American Indian Higher Education
            Consortium for title III (section 316) of the Higher Education
            Act (Strengthening Institutions program) that provides
            construction funds for facilities at tribally controlled
            colleges. This is $4 million more than the fiscal year 2010
            level. Among UTTC's pressing facility needs is funding for
            phase II of our science and technology building and for student
            housing. We are working to cobble together various sources of
            funding to complete the science and technology building and to
            build student housing.
      --$973 million for the TRIO programs nationally which is $120 million
            more than the requested amount. This would replace the $57
            million in mandatory funding that is expiring for the Upward
            Bound program plus provide an increase for other TRIO programs.
        Base Funding.--Funds requested under section 117 of the Perkins Act
    above the fiscal year 2010 level are needed to: (1) maintain 100-year-
    old education buildings and 50-year-old housing stock for students; (2)
    upgrade technology capabilities; (3) provide adequate salaries for
    faculty and staff (who have not received a cost of living increase this
    year and who are in the bottom quartile of salary for comparable
    positions elsewhere); and (4) fund program and curriculum improvements,
    including at least three 4-year degree programs.
        Acquisition of additional base funding is critical as UTTC has more
    than tripled its number of students within the past 6 years, but actual
    base funding for educational services has increased only 25 percent in
    that period. Our Perkins funding provides a base level of support
    allowing the college to compete for discretionary contracts and grants
    leading to additional resources annually for the college's programs and
    support services.
        Title III (Section 316) Strengthening Institutions.--We need title
    III construction funds for:
      --Science and Technology Building.--UTTC provides education for more
            than 1,000 students in 100-year old former military buildings
            (Fort Abraham Lincoln), along with one 33-year old ``skills
            center'' which is inadequate for modern technology and science
            instruction. We have completed phase I of the building and now
            look to complete phase II. We have raised $5 million, including
            $1 million in private funding, $3 million from the U.S.
            Department of Education and $1 million in borrowed funds. The
            total project cost is expected to be around $12 million. Our
            current facility lacks laboratories with proper ventilation and
            other technologies which are standard in science education. We
            lack a modern auditorium/lecture hall with features such as
            computer Internet access and electrical outlets and a library
            with appropriate computer stations. Our present library has
            been cited by the accrediting agency as being inadequate.
      --Student Housing.--We are constantly in need of more student
            housing, including family housing. We would like to educate
            more students but lack of housing has at times limited the
            admission of new students. With the expected completion of a
            new Science and Math building on our South Campus on land
            acquired with a private grant, we urgently need housing for up
            to 150 students, many of whom have families. New housing on the
            South Campus could also accommodate those persons we expect to
            enroll in a new police training programs.
          While UTTC has constructed three housing facilities using a
            variety of sources in the past 20 years, approximately 50
            percent of students are housed in the 100-year-old buildings of
            the old Fort Abraham Lincoln, as well as in duplexes and
            single-family dwellings that were donated to UTTC by the
            Federal Government along with the land and Fort buildings in
            1973. These buildings require major rehabilitation. New
            buildings for housing are actually cheaper than trying to
            rehabilitate the old buildings that now house students.
        TRIO Programs.--UTTC currently has no TRIO funding. We are in
    particular need of funding from the student Support Services Program to
    improve retention, transfer, and graduation rates for our Pell Grant
    recipients. Our students need tutoring, mentoring, academic counseling
    and career development services to help them successfully complete
    their academic courses of study. Our study body meets the eligibility
    requirements of TRIO's Student Support Services program.
      --83 percent of students meet the low-income criteria for TRIO's
            Student Support Services.
      --68 percent of our students are first generation college attendees.
      --17 percent of all UTTC applicants in 2008 had a Graduate
            Equivalency Diploma.
      --74 percent of our students need remediation in math, reading and
            composition.
      --80 percent of our students have Limited English proficiency.
        With regard to our students with a Limited English background, we
    note that although not all UTTC students speak their Native language
    fluently, many speak forms of English that differ from Standard English
    because of the influence of other languages' vocabulary, intonation,
    and vernacular. Although UTTC strongly supports the preservation and
    use of Native languages, our students tend to have difficulty reading,
    writing, and speaking the Standard English as is required of them by
    the College and the workplace.
        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.
        Below are some important things we would like you to know about our
    UTTC:
      --UTTC Performance Indicators.--UTTC has:
        --An 85 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 one of only two
                tribal colleges accredited to offer accredited on-line
                (Internet-based) associate degrees.
        --More than 20 percent of graduates go on to 4-year or advanced
                degree institutions.
      --Our Students.--Our students are from Indian reservations throughout
            the Nation, with a significant portion of them being from the
            Great Plains area. Our students have had to make a real effort
            to attend college; they 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 Perkins funds, 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. We are
            currently serving 168 students in our elementary school and 169
            youngsters in our child development centers.
      --UTTC Course Offerings and Partnerships With Other Educational
            Institutions.--We offer accredited vocational/technical
            programs that lead to 17 2-year degrees (Associate of Applied
            Science and 11 1-year certificates, as well as a 4-year degree
            in elementary education in cooperation with Sinte Gleska
            University in South Dakota. We intend to expand our 4-year
            degree programs. While full information may be found on our Web
            site (www.uttc.edu), among our course offerings are:
        --Licensed Practical Nursing.--This program results in great demand
                for our graduates; students are able 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.--This 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. This program has in
                the past been supported by the IHS, and is the only degree-
                granting Injury Prevention program in the Nation. Given the
                overwhelming health needs of Native Americans, we continue
                to seek resources for training of 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. 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.
        --Criminal Justice.--Our criminal justice program leads many
                students to a career in law enforcement, and as noted
                elsewhere in this testimony, we are actively working on
                establishing a police training academy at UTTC.
        --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.--We help meet the challenge of
                fighting diabetes and other health problems in Indian
                Country through education and research. 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. There
                are few Indian professionals in the country with training
                in these areas. We have also established a Diabetes
                Education Center that assists local tribal communities, our
                students and staff to decrease the prevalence of diabetes
                by providing food guides, educational programs, training
                and materials.
        Our Perkins and Bureau of Indian Education funds provide for nearly
    all of our core postsecondary educational programs. Very little of the
    other funds we receive may be used for core career and technical
    educational programs; they are competitive, often one-time supplemental
    funds which help us provide the services our students need to be
    successful. We cannot continue operating without Perkins funds.
        Thank you for your consideration of our requests.

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    Adult Congenial Heart Association, Prepared Statement of the.....   273
    Alliance for Aging Research, Prepared Statement of the...........   266
    American:
        Academy:
            Of:
                Family Physicians, Prepared Statement of the.........   246
                Nurse Practitioners, Prepared Statement of the.......   259
                Ophthalmology, Prepared Statement of the.............   260
                Physician Assistants, Prepared Statement of the......   263
            For Cancer Research, Prepared Statement of the...........   240
        Association:
            For:
                Dental Research, Prepared Statement of the...........   243
                Geriatric Psychiatry, Prepared Statement of the......   248
            Of:
                Colleges of:
                    Nursing, Prepared Statement of the...............   234
                    Osteopathic Medicine, Prepared Statement of the..   237
                    Pharmacy, Prepared Statement of the..............   238
                Immunologists, Prepared Statement of the.............   251
                Nurse Anesthetists, Prepared Statement of the........   257
        Brain Coalition, Prepared Statement of the...................   268
        College of:
            Cardiology, Prepared Statement of the....................   270
            Physicians, Prepared Statement of the....................   277
            Preventive Medicine, Prepared Statement of the...........   280
            Sports Medicine, Prepared Statement of the...............   284
        Congress of Obstetricians and Gynecologists, Prepared
          Statement of
          the........................................................   274
        Dental Education Association, Prepared Statement of the......   289
        Diabetes Association, Prepared Statement of the..............   286
        Heart Association, Prepared Statement of the.................   294
        Indian Higher Education Consortium, Prepared Statement of the   297
        Institute for Medical and Biological Engineering, Prepared
          Statement of the...........................................   299
        Liver Foundation, Prepared Statement of the..................   306
        Lung Association, Prepared Statement of the..................   304
        Mosquito Control Association, Letter From the................   309
        National Red Cross, Prepared Statement of the................   317
        Nurses Association, Prepared Statement of the................   314
        Physical Therapy Association, Prepared Statement of the......   334
        Physiological Society, Prepared Statement of the.............   329
        Psychological Association, Prepared Statement of the.........   324
        Public Power Association, Prepared Statement of the..........   329
        Society:
            For:
                Microbiology, Prepared Statements of the...........346, 349
                Nutrition, Prepared Statement of the.................   354
            Of:
                Clinical Oncology, Prepared Statement of the.........   345
                Mechanical Engineers, Prepared Statement of the......   352
                Plant Biologists, Prepared Statement of the..........   356
                Tropical Medicine and Hygiene, Prepared Statement of
                  the................................................   358
        Thoracic Society, Prepared Statement of the..................   361
    Americans for Nursing Shortage Relief, Prepared Statement of the.   319
    Animal Welfare Institute, Prepared Statement of the..............   364
    Arthritis Foundation, Prepared Statement of the..................   292
    Association:
        For:
            Clinical Research Training (ACRT), Prepared Statement of
              the....................................................   282
            Professionals in Infection Control and Epidemiology,
              Prepared Statement of the..............................   327
            Psychological Science, Prepared Statement of the.........   331
            Research in Vision & Ophthalmology, Prepared Statement of
              the....................................................   342
        Of:
            American:
                Cancer Institutes, Prepared Statement of the.........   231
                Medical Colleges, Prepared Statement of the..........   254
            Independent Research Institutes, Prepared Statement of
              the....................................................   302
            Maternal and Child Health Programs, Prepared Statement of
              the....................................................   310
            Minority Health Professions Schools, Prepared Statement
              of the.................................................   312
            Organ Procurement Organizations, Prepared Statement of
              the....................................................   322
            Public Television Stations and Public Broadcasting
              Service, Prepared Statement of the.....................   337
            Rehabilitation Nurses, Prepared Statement of the.........   340

    Bern, Chris, President, Iowa State Education Association.........   141
        Prepared Statement of........................................   142
    Brain Injury Association of America, Letter From the.............   369
    Building and Construction Trades Department AFL-CIO, Prepared
      Statement of the...............................................   366

    CAEAR Coalition, Prepared Statement of the.......................   370
    Center For:
        American Progress Action Fund, Prepared Statement of the.....   379
        Civic Education, Prepared Statement of the...................   381
    Charles R. Drew University of Medicine and Science, Prepared
      Statement of the...............................................   386
    Children's Environmental Health Network, Prepared Statement of
      the............................................................   388
    Children and Adults with Attention-Deficit/Hyperactivity
      Disorder, Prepared Statement of................................   394
    Close Up Foundation, Prepared Statement of the...................   406
    Cochran, Senator Thad, U.S. Senator From Mississippi:
        Prepared Statement of........................................ 2, 71
        Questions Submitted by.................................96, 165, 227
        Statements of...........................................2, 111, 172
    Collins, Francis S., M.D., Ph.D., Director, National Institutes
      of Health, Department of Health and Human Services.............   171
        Prepared Statement of........................................   176
        Summary Statement of.........................................   173
    Coalition:
        For:
            Health Services Research, Prepared Statement of the......   396
            The Advancement of Health Through Behavioral and Social
              Science Research, Prepared Statement of the............   376
        Of Northeastern Governors, Prepared Statement of the.........   399
    Corporation for:
        Public Broadcasting, Prepared Statement of the...............   401
        Supportive Housing, Prepared Statement of the................   404
    Cortines, Ramon C., Superintendent, Los Angeles Unified School
      District.......................................................   136
        Prepared Statement of........................................   138
    Council of Academic Family Medicine, Prepared Statement of the...   373
    Crohn's and Colitis Foundation of America, Prepared Statement of
      the............................................................   384
    Cystic Fibrosis Foundation, Prepared Statement of the............   391

    Duncan, Hon. Arne, Secretary, Office of the Secretary, Department
      of Education...................................................   109
        Prepared Statement of........................................   116
        Questions Submitted to.......................................   158
        Summary Statement of.........................................   112
    Durbin, Senator Richard J., U.S. Senator From Illinois, Questions
      Submitted by...................................................    41
    Dystonia Medical Research Foundation, Prepared Statement of the..   408

    Elder Justice Coalition, Prepared Statement of the...............   410
    Eldercare Workforce Alliance, Prepared Statement of the..........   410
    Endocrine Society, Prepared Statement of the.....................   628

    Family Voices, Inc., Prepared Statement of.......................   428
    Federation of:
        American Societies for Experimental Biology, Prepared
          Statement of
          the........................................................   414
        Associations in Behavioral and Brain Sciences, Prepared
          Statement of the...........................................   412
    Friends of:
        NIAAA, Prepared Statement of the.............................   416
        NICHD, Prepared Statement of the.............................   419
        The National Institute on Aging, Prepared Statement of the...   422
    FSH Society, Inc., Prepared Statement of the.....................   425

    Goodwill Industries International, Prepared Statement of.........   431

    Harkin, Senator Tom, U.S. Senator From Iowa:
        Opening Statements of...............................1, 51, 109, 171
        Questions Submitted by..................................28, 78, 214
    Harlem United Community AIDS Center, Inc., Prepared Statement of
      the............................................................   451
    Health Professions and Nursing Education Coalition, Prepared
      Statement of the...............................................   443
    Hepatitis:
        Appropriation Partnership, Prepared Statement of the.........   433
        B Foundation, Prepared Statement of the......................   435
        Outbreaks National Organization for Reform (HONOReform),
          Prepared Statement of the..................................   441
    Herzog, Marc S., Chancellor, Connecticut Community Colleges......   148
        Prepared Statement of........................................   150
    HIV:
        Health and Human Services Planning Council of New York,
          Letter From the............................................   437
        Medicine Association, Prepared Statement of the..............   438
    Home Safety Council, Prepared Statement of the...................   446
    Humane Society of the United States, Prepared Statement of the...   448

    Industrial Minerals Association--North America, Letter From the..   455
    Inouye, Senator Daniel K., U.S. Senator From Hawaii:.............
        Prepared Statement of........................................     2
        Questions Submitted by..................................31, 87, 215
    Interstate Mining Compact Commission, Prepared Statement of the..   456
    International:
        Foundation for Functional Gastrointestinal Disorders,
          Prepared Statement of the..................................   453
        Myeloma Foundation, Prepared Statement of the................   457

    Jeffrey Modell Foundation, Prepared Statement of the.............   458

    Knowledge Alliance, Prepared Statement of........................   461

    Landrieu, Senator Mary L., U.S. Senator From Louisiana, Questions
      Submitted by..............................................38, 94, 158
    Lions Clubs International Foundation, Prepared Statement of the..   464

    March of Dimes Foundation, Prepared Statement of the.............   476
    McConnell, Senator Mitch, U.S. Senator From Kentucky, Question
      Submitted by...................................................   106
    Meharry Medical College, Prepared Statement of...................   474
    Medical Library Association, Prepared Statement of the...........   472
    Mended Hearts, Incorporated, Prepared Statement of...............   471
    MENTOR/National Mentoring Partnership, Prepared Statement of.....   467
    Montgomery County Stroke Association, Prepared Statement of the..   467
    Morehouse School of Medicine, Prepared Statement of the..........   479
    Morton, Joseph B., Ph.D., State Superintendent of Education,
      Alabama State Department of Education..........................   144
        Prepared Statement of........................................   146
    Murray, Senator Patty, U.S. Senator From Washington, Questions
      Submitted by...................................................33, 90

    National:
        AHEC Organization, Prepared Statement of the.................   496
        Alliance:
            For Eye and Vision Research, Prepared Statement of the...   490
            Of State & Territorial AIDS Directors, Prepared Statement
              of the.................................................   502
            On Mental Illness, Prepared Statement of the.............   493
        Assembly on School-based Health Care, Prepared Statement of
          the........................................................   501
        Association:
            For Public Health Statistics and Information Systems,
              Prepared Statement of the..............................   497
            Of:
                Children's Hospitals, Prepared Statement of the......   486
                Community Health Centers, Prepared Statement of the..   488
                County and City Health Officials, Prepared Statement
                  of the.............................................   484
                Local Boards of Health, Prepared Statement of the....   492
                People With AIDS and Villagecare, Prepared Statement
                  of the.............................................   499
                Workforce Boards, Prepared Statement of the..........   505
        Coalition:
            For:
                Literacy, Prepared Statement of the..................   514
                Osteoporosis and Related Bone Diseases, Prepared
                  Statement of the...................................   520
            Of STD Directors, Prepared Statement of the..............   522
        Consumer Law Center, Prepared Statement of the...............   517
        Council:
            For Diversity in the Health Professions, Prepared
              Statement of the.......................................   510
            Of State Directors of Adult Education, Prepared Statement
              of the.................................................   525
        Down Syndrome Society, Prepared Statement of the.............   526
        Eczema Association, Prepared Statement of the................   527
        Federation of Community Broadcasters, Prepared Statements of
          the......................................................511, 529
        Health Care for the Homeless Council, Prepared Statement of
          the........................................................   531
        Kidney Foundation, Prepared Statement of the.................   533
        Marfan Foundation, Prepared Statement of the.................   536
        Minority Consortia, Prepared Statement of the................   533
        Postdoctoral Association, Prepared Statement of the..........   539
        Primate Research Centers, Prepared Statement of the..........   546
        Psoriasis Foundation, Prepared Statement of the..............   541
        Public Radio, Prepared Statement of..........................   543
        REACH Coalition for the Elimination of Health Disparities,
          Prepared Statement of the..................................   551
        Recreation and Park Association, Prepared Statement of the...   552
        Respite Coalition, Prepared Statement of the.................   548
        Sleep Foundation, Prepared Statement of the..................   554
        Technical Institute for the Deaf, Prepared Statement of the..   556
        Wildlife Federation, Prepared Statement of the...............   560
    Nephcure Foundation, Prepared Statement of the...................   630
    North American Brain Tumor Coalition, Prepared Statement of the..   481
    Nursing Community, Prepared Statement of the.....................   507

    Oncology Nursing Society, Prepared Statement of the..............   565
    Ovarian Cancer National Alliance, Prepared Statement of the......   563

    Public Health--Seattle and King County, Letter From..............   587
    Pancreatic Cancer Action Network, Prepared Statement of the......   580
    Patient Alliance for Neuroendocrineimmune Disorders Organization
      for Research and Advocacy, Prepared Statement of the...........   572
    Pew Children's Dental Campaign, Prepared Statement of the........   582
    Physician Assistant Education Association, Prepared Statement of
      the............................................................   570
    PKD Foundation, Prepared Statement of the........................   588
    Population Association of America/Association of Population
      Centers, Prepared Statement of the.............................   568
    Prevent Blindness America, Prepared Statement of the.............   577
    Proliteracy Worldwide, Prepared Statement of the.................   590
    Program for Appropriate Technology In Health, Prepared Statement
      of the.........................................................   574
    Pryor, Senator Mark, U.S. Senator From Arkansas, Questions
      Submitted by..................................................46, 164
    Pulmonary Hypertension Association, Prepared Statement of the....   585

    Railroad Retirement Board, Prepared Statements of the..........592, 594
    Reed, Senator Jack, U.S. Senator From Rhode Island:
        Statements of................................................    74
        Questions Submitted by..................................43, 95, 161
    Ryan White Medical Providers Coalition, Prepared Statement of the   596

    Scleroderma Foundation, Prepared Statement of the................   632
    Sebelius, Hon. Kathleen, Secretary, Office of the Secretary,
      Department of Health and Human Services........................     1
        Summary Statement of.........................................     3
        Prepared Statement of........................................     5
    Sexuality Information and Education Council of the United States,
      Prepared Statement of the......................................   609
    Shelby, Richard C., U.S. Senator From Alabama, Questions
      Submitted by...................................................   230
    Society for:
        Healthcare Epidemiology of America, Prepared Statement of the   606
        Maternal-Fetal Medicine, Prepared Statement of the...........   612
        Neuroscience, Prepared Statement of the......................   603
        Public Health Education, Prepared Statement of the...........   614
        Women's Health Research, Prepared Statement of the...........   616
    Solis, Hon. Hilda. L, Secretary, Office of the Secretary,
      Department of Labor............................................    51
        Prepared Statement of........................................    55
        Summary Statement of.........................................    53
    Specter, Senator Arlen, U.S. Senator From Pennsylvania:
        Statements of...............................................71, 196
        Questions Submitted by......................................46, 225
    Spina Bifida Association and Spina Bifida Foundation, Prepared
      Statement of the...............................................   598
    Status C Unknown, Prepared Statement of the......................   601

    Telehealth Leadership Initiative, Prepared Statement of the......   629
    The AIDS Institute, Prepared Statement of........................   623
    Tri-Council for Nursing, Prepared Statement of the...............   626
    Trust for America's Health, Prepared Statement of the............   620

    United Tribes Technical College, Prepared Statement of the.......   635

                                 SUBJECT INDEX

                                  ----------

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

                                                                       Page

    Access to Higher Education.......................................   114
    Additional Committee Questions...................................   158
    Addressing the Achievement and Opportunity Gaps..................   131
    Administrative Cost of 100 Percent Direct Lending................   115
    Approach to ESEA Reauthorization.................................   132
    ARRA.............................................................   115
        Funding......................................................   128
    California's Bad News Budget.....................................   138
    Career:
        And Technical Education......................................   166
        Pathways Innovation Fund.....................................   153
    Charter Schools--Expanding Educational Options Program...........   160
    College Access:
        And:
            Career Readiness.......................................116, 118
            Completion...............................................   119
        Challenge Grants (CACG)......................................   161
    Commitment to Improving Education................................   113
    Comparability of Educational Services............................   131
    Competitive Ability of Rural and Small Districts.................   130
    Comprehensive Solutions..........................................   119
    Consolidations...................................................   125
    Defining and Funding Early Learning Education....................   121
    Dropout Rate.....................................................   123
    Early Learning Challenge Fund..................................115, 168
    Education:
        Jobs Bill..................................................121, 152
        Layoffs......................................................   110
    Educational Technology...........................................   168
    Effective:
        Teachers and School Leaders..................................   118
        Teaching and Learning: Literacy Program......................   162
    Emergency Jobs Bill for Education................................   134
    Enrollment Surge.................................................   150
    ESEA Reauthorization and Fiscal Year 2011 Budget Request.........   114
    Evaluation of Teacher Quality Partnership Grants.................   164
    Federal:
        Direct Student Loans Program.................................   129
        Student Support Services and Institutional Aid...............   153
    Fiscal Year 2011:
        Funding......................................................   152
        Budget Request:
            And ESEA Reauthorization.................................   118
            Increase over 2010.......................................   110
    Fully Fund Special Education.....................................   139
    Funding:
        Excellence in Education......................................   128
        For Early Childhood Education in 2010........................   122
    Geographic Education.............................................   165
    Goals of Reform Strategies.......................................   115
    Guidance on Use of Federal Funds to Support Libraries............   162
    High School Graduation Rate......................................   134
    History and Civics Education.....................................   129
    Impact of:
        Layoffs and Cutbacks on Overall Economy......................   113
        Weak Economy on Education....................................   133
    Improving:
        Outcomes for:
            Adult Learners...........................................   120
            Persons With Disabilities................................   120
        Stem Outcomes................................................   119
    Incorporating Early Learning Into Federal Education Programs.....   168
    Innovation.......................................................   140
    Introduction of Education Jobs Panel.............................   135
    Investing in Innovation Fund.....................................   125
    Keep Our Educators Working Bill..................................   110
    Leveraging Educational Assistance Partnership (LEAP) Program.....   161
    Migrant Education Program........................................   125
    National Writing Project.........................................   165
    Need for Additional Emergency Education Funds....................   116
    Not Satisfied With Chronic Failure...............................   140
    Number of Urban vs. Rural School Districts.......................   131
    Pell Grant Shortfall.............................................   111
    Perkins Career and Technical Education Programs..................   153
    President Obama's 2011 Budget Request............................   117
    Program:
        Consolidation Proposal and Prospective Applicants............   165
        Consolidations.............................................125, 165
    Progress.........................................................   140
    Promise Neighborhoods Initiative.................................   133
    Public Television Children's Programming.........................   167
    Race to the Top..................................................   158
        Application Scoring..........................................   126
        Competition................................................113, 122
        First Round Competition....................................126, 128
        Funding......................................................   123
    Reach of CTE Programs and Steps to Improve CTE Programs..........   166
    Ready to Learn...................................................   167
    Recognizing Achievement..........................................   132
    Replicating Promising Practices and Strategies...................   169
    Rural:
        And Low-income School District Funding.......................   124
        Districts Ability to Compete for Grants......................   134
        Education Achievement Program (REAP).........................   125
    School:
        Improvement Grant Funding....................................   124
        Libraries....................................................   162
        Turnaround Grants............................................   164
    State:
        And Local Level Education Cutbacks and Layoffs...............   112
        Budget Crisis and Stimulus Funding...........................   151
        Educational Standards........................................   113
        Improvement Grants and Investing in Innovation...............   114
    Stop the State From Hijacking Funds Washington Intends for Public
      Education......................................................   139
    Strengthening Teacher Preparation Programs.......................   163
    Student Aid:
        And Fiscal Responsibility Act................................   110
        Funding......................................................   115
    Teach For America (TFA)........................................127, 129
    Teacher:
        And Leader:
            Innovation Fund..........................................   160
            Pathways Program.......................................159, 164
        Incentive Fund.............................................129, 160
        Preparation..................................................   164
        Quality Partnership Grants...................................   163
    The:
        Federal Pell Grant Program...................................   153
        Uniqueness of the Los Angeles Unified School District........   140
    TIF Investment...................................................   130
    Training, Retaining, and Recruiting Teachers.....................   114
    21st Century Community Learning Centers..........................   167
    What:
        More Can Washington Do--More Money for Disadvantaged Students   139
        Washington Can Do--Jobs, Jobs, Jobs..........................   139

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    Additional Committee Questions...................................   214
    Allied Health Schools in Remote Communities......................   216
    Alzheimer's Disease..............................................   194
    American Recovery and Reinvestment Act (ARRA)....................   214
    Autologous Stem Cells..........................................210, 212
    Biodefense.......................................................   230
    Biomedical Research Propels U.S. Economy.........................   180
    Burden of Disease................................................   203
    Cancer:
        Prevention...................................................   220
        Research...................................................221, 223
    Chronic Kidney Disease...........................................   217
    Clinical Center..................................................   225
    Collaborative Cancer Research....................................   219
    Crohn's Disease..................................................   228
    Cures Acceleration Network................................196, 199, 225
    Diabetes.........................................................   218
    Discoveries on the Horizon.......................................   190
    FDA and the NIH..................................................   206
    Fiscal Year 2010 and Post-ARRA...................................   189
    Flexible Research Authority......................................   200
    Grant Restrictions...............................................   215
    Hepatitis B......................................................   217
    How far:
        We Have to go................................................   178
        We've Come...................................................   177
    Imagine the Future...............................................   181
    Institute of Medicine (IOM) Report on Clinical Trials............   192
    Institutional Development........................................   195
        Award (IDEA).................................................   229
    Jackson Heart Study..............................................   191
    Lowell P. Weicker Conference Room................................   215
    Medline Plus.....................................................   214
    Minority Health..................................................   228
    National Center on Minority Health and Health Disparities (NCMHD)   202
    NicVAX Smoking Vaccine...........................................   187
    Nursing Research.................................................   215
    Pancreatic Cancer..............................................204, 226
    Patient Advocates................................................   207
    Sickle Cell Disease..............................................   210
    Smoking Vaccine..................................................   187
    Spinal Muscular Atrophy (SMA)....................................   227
    Stem Cells.......................................................   207
        For Spinal Cord Injuries.....................................   209
    The Research Marathon............................................   177
    Therapeutics for Rare and Neglected Diseases Program.............   200
    Transforming Discovery into Health...............................   179
    Tuberculosis.....................................................   223
    Under-represented Biomedical Researchers.........................   224

                            Office of the Secretary

    Abstinence.......................................................    46
    Additional Committee Questions...................................    28
    American Recovery and Reinvestment Act (ARRA)....................    46
    Anthrax Vaccine..................................................    48
    Antimicrobial Resistance.........................................    37
    Bioproduction Facility...........................................    48
    Blood Disorders..................................................    31
    Breast Cancer Screening..........................................    30
    Childhood Obesity Prevention.....................................    42
    Community Health Centers (CHC)...............................31, 40, 43
    Communities Putting Prevention to Work...........................    20
    Critical Access Hospitals (CAH)..................................    41
    Early Childhood:
        Education....................................................    29
        Programs.....................................................    11
    Fostering Connections to Success and Increasing Adoptions Act....    38
    Geographic Variance in Medicare Reimbursement....................    17
    Health Professions Programs......................................    41
    Healthcare:
        Reform.......................................................    40
        Worker Vaccination...........................................    45
    H1N1 Emergency Supplemental......................................    10
    Let's Move Campaign..............................................    12
    Low Income Home Assistance Program (LIHEAP)......................14, 43
    MAPPS Interventions..............................................    21
        For Communities Putting Prevention to Work...................    21
    Medicaid Coverage................................................    41
    Medical Countermeasures..........................................    29
    Medicare:
        Part D.......................................................    47
        Secondary Payer (MSP)........................................    43
    Mental Health Services...........................................    39
    Ocean State Crohn's and Colitis Area Registry....................    46
    Pandemic Preparedness............................................    18
    Project Bioshield................................................    28
    Sexually Transmitted Diseases (STDs) Prevention in Teens.........    37
    Teen-pregnancy Prevention Initiatives............................    34
    The Hemophilia Program (CDC).....................................    45
    Title:
        VII Health Professions Funding...............................    45
        X............................................................    34
    Tobacco Lab......................................................    31
    Vaccinations--Section 317 Immunization Program...................    44
    Vaccine:
        Preventable Deaths...........................................    38
        Production and Distribution Infrastructure...................    18
    Waste, Fraud, and Abuse..........................................10, 26
    Workforce/Sustainable Growth Rate (SGR)..........................    33

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................    78
    Apprenticeships..................................................    90
    Budget Deficit...................................................   105
    Bureau of Labor Statistics (BLS).................................    93
    Decrease in Funding..............................................    71
    Denison Job Corps................................................    67
    Disability Employment Initiative.................................54, 65
        Program Navigators...........................................    66
    Employee Misclassification.......................................    54
    Employment and Training Administration (ETA).....................    78
    Ensuring Accountability and Transparency.........................    62
    Ergonomics Enforcement...........................................    85
    Evaluations of State Plans.......................................    85
    Extending Temporary Waiver of Interest Payments..................    75
    Federal Unemployment Benefits and Allowances.....................   102
    Fiscal Year 2011 Budget..........................................    52
    Foreign Labor Certification......................................    98
    G20 Labor Minister's Meeting.....................................    69
    Green Jobs Innovation Fund.......................................    54
    Hiring Plan for Enforcement Staff................................    85
    Hurricane Katrina................................................    69
    ILAB.............................................................    68
    Injury and Illness Recordkeeping.................................    84
    Job Corps........................................................66, 97
    Mine Safety......................................................    73
    Misclassification................................................    92
    New Workforce Innovation Fund....................................    76
    Office of Labor Management Standards (OLMS).....................70, 104
    Other Programs...................................................    63
    Preparing for Jobs of the Future.................................    56
    Proposed Freeze on Discretionary Spending........................    52
    Protecting Workers' Rights and Safety............................    59
    Putting People Back to Work......................................    55
    Recovery Act Resources...........................................    53
    Regulations......................................................    91
    Senior Community Service Employment Program (SCSEP)..............    87
    State Programs...................................................    90
    SUIESO...........................................................    83
    Summer Youth Employment..........................................    77
    Supplemental Appropriation for Summer Youth Employment...........    77
    Timelines for Rulemakings........................................    86
    Underground Communications and Tracking Equipment................    74
    Unemployment Rate................................................    53
    Veterans Employment and Training Service (VETS)..................    72
    Voluntary Protection Programs....................................    94
    Worker Protection................................................    65
        Programs.....................................................    54
    Workforce Investment Act (WIA) Workforce Innovation Fund (WIF)...    96
        Programs.....................................................    53

                                       -