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



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

                              ----------                              


                         TUESDAY, JUNE 9, 2009

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

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                        Office of the Secretary

STATEMENT OF HON. KATHLEEN SEBELIUS, SECRETARY


                opening statement of senator tom harkin


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


           healthcare waste and hospital-acquired infections


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


              summary statement of hon. kathleen sebelius


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


                           healthcare reform


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


                         healthcare disparities


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


                              pandemic flu


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


                           prepared statement


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

           HEALTHCARE WASTE AND HOSPITAL-ACQUIRED INFECTIONS

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

                [From The Washington Post, June 9, 2009]

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

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

                        PREVENTION AND WELLNESS

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

                       LIHEAP FUNDING DISPARITIES

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

                         QUALITY OF HEALTHCARE

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

                    A PUBLIC HEALTH INSURANCE OPTION

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

                   HEALTHCARE ACCESS IN RURAL AMERICA

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

                              NIH FUNDING

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

             UNIVERSITY OF PITTSBURGH BIODEFENSE INITIATIVE

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

                          NIH STIMULUS FUNDING

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

                       HEALTHCARE FRAUD AND ABUSE

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

                     ADDITIONAL COMMITTEE QUESTIONS

    Well, Madam Secretary, thank you very much for your 
appearance here and your leadership at the Department. I will 
leave the record open for any written questions that the 
Senators who couldn't be here might want to propound. And, 
again, I look forward to working with you on the recovery money 
that we talked about before that's going out for prevention.
    Secretary Sebelius. Absolutely. Thank you.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
            Questions Submitted by Senator Daniel K. Inouye
            occupational safety and health training program
    Question. Several years ago, at my request, the Centers for Disease 
Control and Prevention (CDC) established a National Institute for 
Occupational Safety and Health presence at the University of Hawaii at 
Hilo. Unfortunately, a now retired faculty member returned the funds. 
With new and energetic faculty now present, will you consider re-
establishing a presence back on the island, given our truly unique 
rural and environmental needs?
    Answer. CDC/NIOSH supported a Training Project Grant at the 
University of Hawaii--Hilo (T02-OH008627, entitled ``Occupational 
Safety and Health Education--A Behavioral Approach,'' from August 2001 
through June 30, 2006. The awarded application was competitively 
reviewed and was awarded based on its technical and scientific merit. 
The Principal Investigator, Dr. Stephen Worchel, Department of 
Psychology, indicated to CDC/NIOSH in August 2005 that the University 
did not plan to recompete for support of this project. The grant ended 
and was subsequently closed out.
    On March 12, 2009, CDC/NIOSH provided a step-by-step process for 
submitting a new application to University of Hawaii at Hilo for a 
Training Project Grant. University officials indicated that the 
University of Hawaii--Hilo planned on submitting a highly competitive 
application for the upcoming August 24 deadline in response to NIOSH's 
Program Announcement PAR-06-484: http://grants.nih.gov/grants/guide/pa-
files/PAR-06-484.html. The most meritorious applications are expected 
to be funded in June 2010.
                       native hawaiian healthcare
    Question. I am very pleased that your department continues to 
recognize the unique health needs of the Native Hawaiian population. I 
appreciate being kept informed of efforts to improve health outcomes, 
especially as they relate to diabetes and cancer in this population.
    Answer. The Department of Health And Human Services (HHS) has a 
number of initiatives, grants, and partnerships to address the needs 
the Native Hawaiian population; attached is a list of some of the 
grants provided to organizations serving Native Hawaiians. In 2006, HHS 
established the HHS Workgroup on Asian, Native Hawaiian and other 
Pacific Islander Issues (WANHOPII). The mission of WANHOPII is to 
improve communication, coordination, and agency policies, programs, and 
evaluations that impact the health, healthcare, human services, and 
well being of Asian American, Native Hawaiian and other Pacific 
Islander (NHOPI) communities. In addition, the Office of Minority 
Health is supporting the development of the Native Hawaiian and Other 
Pacific Islander Health Agenda, including town hall meetings and 
summits that provide a forum for NHOPI community members, community-
based organizations, and others to voice their issues, concerns, and 
recommendations, and to mobilize around a health and well-being agenda 
to address NHOPI health.
    Several HHS offices and agencies have programs to improve health 
outcomes, including those related to diabetes and cancer, of the Native 
Hawaiian population. Summaries are provided below:
                       office of minority health
    The Office of Minority Health (OMH) supported the development of 
the Native Hawaiian and Other Pacific Islander Health Agenda introduced 
by the Asian and Pacific Islander American Health Forum (APIAHF), and 
provided additional funding to APIAHF to explore health issues facing 
Native Hawaiians and Pacific Islanders.
    In April 2007, OMH supported the California Native Hawaiian and 
Pacific Islander Town Hall Meeting to provide a forum for NHOPI 
community members, community-based organizations, and others working 
with NHOPI populations to voice their issues, concerns, and 
recommendations regarding NHOPI health to the HHS. The town hall and 
subsequent discussions resulted in the first ever Native Hawaiian and 
Pacific Islander Health and Well-Being Summit in October 2007 to 
articulate and mobilize around a health agenda. HHS recognizes that 
NHOPI communities have unique health needs, and has supported APIAHF in 
the formation of the Native Hawaiian and Pacific Islander Alliance. On 
January 30, 2008, APIAHF with the NHPI Alliance released the report 
``Guidance for the classification of Native Hawaiians and Pacific 
Islanders'' that appropriately reflects the disaggregation of Asian 
Americans, Native Hawaiians, and Pacific Islanders.
    In April 2009, OMH co-sponsored the Native Hawaiian and Pacific 
Islander Health Brain Trust, hosted by the APIAHF. The 2009 Brain Trust 
was the first of a two-series conference to learn about pressing health 
issues and discuss barriers to data collection and reporting on Native 
Hawaiians and Pacific Islanders, and to identify strategies for 
community and community-based organizations, researchers, funding 
agencies, policy makers, and advocates for improving the health and 
well-being of Native Hawaiians and Pacific Islanders.
    OMH also works closely with our community partners, including Papa 
Ola Lokahi, to respond to the concerns and needs of the Native Hawaiian 
community. Through the Youth Empowerment Program, OMH supports the 
Lanakila Learning Center through the University of Hawaii at Hilo. The 
Lanakila Learning Center is an alternative learning center of Hilo High 
School servicing ``at-risk'' 10th-12th graders, and providing a variety 
of wellness workshops in substance abuse prevention/intervention, 
social skills training, anger management, health and nutrition, and 
fitness classes.
    Through the Community Partnerships to Eliminate Health Disparities 
grant program, OMH supports the Life Foundation, a program that seeks 
to improve the health status of Native Hawaiians, Asians, and Pacific 
Islanders through targeted HIV prevention and care services. Life 
Foundation partners with Waikiki Health Center and Waianae Coast 
comprehensive Health Center.
              health resources and services administration
    The Health Resources and Services Administration (HRSA) provide 
funding for the Native Hawaiian Health Care Program, which is funded 
through the Health Center appropriation. The focus is to improve the 
health status of Native Hawaiians by making health education, health 
promotion, and disease prevention services available through the 
support of the Native Hawaiian Healthcare Systems. The Native Hawaiian 
Healthcare Systems use a combination of outreach, referral, and linkage 
mechanisms to provide or arrange services. Services provided include 
nutrition programs, screening and control of hypertension and diabetes, 
immunizations, and basic primary care services. In fiscal year 2007, 
Native Hawaiian Healthcare Systems provided medical and enabling 
services to more than 6,500 people. The Native Hawaiian population is 
also served by the Health Centers operating more broadly across Hawaii.
      niddk's diabetes education in tribal schools (dets) project
    The National Institute of Diabetes and Digestive and Kidney 
Diseases (NIDDK) has provided funding to eight tribal colleges and 
Universities to develop supplemental curricula on diabetes education 
for K-12 schools that educate American Indian and Alaska Native 
children. The curricula are completed and the investigators are now 
recruiting and training teachers in the K-12 schools. Recently, the 
investigators were invited by some schools in Maui to provide 
professional education to their teachers so they can also use the DETS 
curricula to teach children in their K-12 schools about diabetes and 
prevention. You may find more information on the DETS at: http://
www3.niddk.nih.gov/fund/other/dets/index.htm.
                hhs national diabetes education program
    The HHS National Diabetes Education Program (NDEP) is the leading 
Federal Government public education program that promotes diabetes 
prevention and control. Launched in 1997, NDEP's mission is to reduce 
the morbidity and mortality associated with diabetes. More than 200 
organizations and many volunteers have joined with NDEP to help develop 
critical and effective initiatives. The NDEP Asian American and Pacific 
Islander Work Group has led development of tip sheets on comprehensive 
diabetes control and the primary prevention of diabetes in 15 Asian and 
Pacific Islander languages. Through the CDC, the NDEP supported Papa 
Ola Lokahi's Pacific Diabetes Education Program, serving Native 
Hawaiians and a diverse population across the Pacific Islands with 
culturally appropriate in-language diabetes materials.
    The Hawaii Diabetes Prevention and Control Program (HI DPCP) has 
received funding from the CDC since 1987. Activities supported by the 
DPCP include surveillance, development of the Hawaii Diabetes 
Coalition, translation, development and distribution of resource 
materials, quality improvement initiatives, and review of the Hawaii 
State Practice Recommendations.
               centers for medicare and medicaid services
    Many of the Centers for Medicare and Medicaid Services (CMS) 
activities have focused on the Native Hawaiian healthcare system (Papa 
Ola Lokahi is the lead agency) along with grants to various Federally 
Qualified Health Centers (FQHCs) and community health centers. CMS also 
funds a Cancer Prevention and Treatment Demonstration for Racial and 
Ethnic Minorities (ending in 2010) at Molokai General Hospital. The 
demonstration is using a randomized control design to study the impact 
of various evidence-based, culturally competent models of patient 
navigator programs designed to help minority beneficiaries navigate the 
healthcare system in a more timely and informative manner and 
facilitate cancer screening, diagnosis, and treatment to improve 
healthcare access and outcomes as well as potentially lower total costs 
to Medicare. Approximately 12,700 Medicare fee-for-service 
beneficiaries are eligible to be enrolled in the study during this 4-
year project.
    Through CMS-funded grants directed to States, State Health 
Insurance Assistance Programs, or SHIPs, provide free counseling and 
assistance to people with Medicare and their families. The Hawaii SHIP 
provides the following activities:
  --Part D/LIS and general Medicare counseling, information and 
        outreach to beneficiaries and information on how the plans will 
        coordinate with the unqualified SPAP which will lead to 
        improved access to medications by beneficiaries. While this is 
        not specifically targeted to diabetes and cancer health 
        outcomes, these activities will help improve access to needed 
        medications for this population.
  --Through the Executive Office on Aging of the Department of Health 
        where the SHIP is housed, the Native Hawaiian programs 
        participate in the Healthy Aging project.
                        administration on aging
    With funding from the U.S. Administration on Aging, Hawaii's 
Executive Office on Aging and Department of Health work together to 
offer Healthy Aging Partnership--Empowering Elders (HAP-EE), which 
began in September 2006. HAP-EE carries out programs that have been 
proven effective in reducing the risk of disease, disability and injury 
among the elderly. These include the Chronic Disease Self-Management 
Program, Arthritis Self-Management Program, Diabetes Self-Management 
Program, and EnhanceFitness. These programs provide seniors with simple 
tools and techniques they can use to better manage their chronic 
conditions, reduce their risk of falling, and improve their nutrition 
and physical health. A pre-poststudy of the Hawaii Chronic Disease 
Self-Management Program reported improvements in physical activity; 
reductions in pain, fatigue and shortness of breath; and a reduction in 
medical care use. Results of pre-poststudy of Enhance Fitness 
participants in Hawaii showed improvements in gait and strength, 
increased levels of physical activity, and reduction in falls.
               centers for disease control and prevention
    The Division of Cancer Prevention and Control provides funding to 
the Hawaii Department of Health, through a cooperative agreement, to 
provide breast and cervical cancer screening and diagnostic services to 
underserved women, including Native Hawaiian women. The Division of 
Cancer Prevention and Control also provides funding to the Hawaii 
Department of Health for the Comprehensive Cancer Control Program. 
Hawaii has a comprehensive cancer control plan that was developed by a 
coalition that includes a diverse group of stakeholders. Coalition 
members include representatives of organizations, such as Papa Ola 
Lokahi, that focus on the needs of the Native Hawaiian population.
                     office on women's health (owh)
    Advancing System Improvements to Support Targets for Healthy People 
2010 (ASIST2010) is a 3-year cooperative agreement program funded by 
the Office on Women's Health. ASIST2010 uses a public health systems 
approach to improve performance on objectives that target women and/or 
men in the following focus areas: cancer, diabetes, heart disease, 
stroke, access to quality health services, educational and community-
based programs, nutrition and overweight physical activity, and 
fitness. Two of the 12 funded ASIST2010 programs targeting diabetes 
include as their target population Pacific Islanders:
  --National Kidney Foundation of Michigan (Ann Arbor, Michigan).--The 
        site utilizes PATH, Tomando Control de su Salud and Enhance 
        Fitness programs to provide people with chronic diseases and 
        those at-risk with the skills and tools needed to improve their 
        health outcomes and manage their symptoms. To assure that the 
        programs are culturally appropriate, leaders and programs are 
        gender-specific as needed to reach certain racial and ethnic 
        minority populations, including African Americans, Hispanic/
        Latinos, Asian Americans/Pacific Islanders, Native Americans, 
        and Arab Americans.
  --Wise Woman Program of Saipan, Commonwealth of the Northern Mariana 
        Islands.--The Wise Woman Village Project (WWVP) of the Northern 
        Marianas Islands Department of Public Health provides outreach, 
        health screening, and education. WWVP addresses noncommunicable 
        diseases (diabetes, mellitus, hypertension, cardiovascular 
        disease, and cervical cancer) in addition to tobacco use 
        assessment and cessation referral. It addresses physical 
        activity promotion through a partnership with a faith-based 
        organization and other community organizations.
  --BodyWorks.--Another OWH program, BodyWorks, is designed to help 
        parents and caregivers of adolescents improve family eating and 
        activity habits. The program focuses on parents as role models 
        and provides them with hands-on tools to make small, specific 
        behavior changes to prevent obesity and help maintain a healthy 
        weight. The program uses a train-the-trainer model to 
        distribute the Toolkit through community-based organizations, 
        State health agencies, nonprofit organizations, health clinics, 
        hospitals and healthcare systems. There are approximately 20 
        trainers in Hawaii; a list can be found at: http://
        www.womenshealth.gov/BodyWorks/
        find.trainers.statedetail.cfm?state=HI.
     administration for children and families: office of head start
    The Office of Head Start provides grants to various entities 
including schools, tribes, and nonprofit and for-profit agencies to 
provide comprehensive child development services to economically 
disadvantaged children and family. A major focus of services to 
enrolled children and their families is towards improving health 
outcomes through the provision of educational, nutritional, and health 
services. These primary and secondary prevention services are making a 
major impact on improving health outcomes for those Native Hawaiian 
children and families that are currently served under existing Head 
Start grants. Hawaii is served under region 9. The most recent 
statewide data (Source: 2008 OHS Program Report Information) shows that 
Head Start funds a total of 7 grantees, and 21 percent of the Hawaii 
State HS/EHS children served are Native Hawaiian or other Pacific 
Islander ethnicity. This includes 1,588 for Head Start and 377 for 
Early Head Start.
    Head Start's goals include prevention and reduction of childhood 
overweight and obesity, to reduce the incidence of Type 2 Diabetes 
Mellitus. Obesity is a major risk factor for the development of Type 2 
Diabetes Mellitus. The Office of Head Start is conducting a major 
initiative to prevent and reduce childhood obesity, through a program 
titled ``I Am Moving, I Am Learning''. I Am Moving, I Am Learning 
introduces multidisciplinary teams from local Head Start programs to 
the science of obesity prevention, and arms them with state-of-the-art 
resources and best practices for addressing the growing child obesity 
epidemic in an intentional and purposeful manner.
    Head Start also works to prevent and reduce tobacco smoke exposure. 
The Family and Child Experiences Survey study shows that 45 percent of 
Head Start families smoke and 56 percent of Early Head Start families 
smoke. The Office of Head Start and the Indoor Environments Division of 
the U.S. Environmental Protection Agency are partnering to improve the 
overall health of Head Start children. The partnership aims to reduce 
young children's exposure to secondhand smoke and other asthma 
triggers. The goal of the partnership is not to get parents to stop 
smoking. Rather, the purpose of the toolkit is for Head Start staff to 
use the information as a means to educate parents of the many ways to 
enhance their children's health.
     hhs grants provided to organizations serving native hawaiians
    Administration for Children and Families/Administration for Native 
Americans (ACF/ANA)
    Grantee.--Wai'anae Coast Comprehensive Health Center
    Project Title.--Strengthening Families and Promoting Healthy 
Lifestyle
    Project Funding.--$542,064 (includes anticipated continuation 
awards)
    Total ANA Funding.--$2,014,024
    The Wai'anae community is located on the western side of the island 
of Oahu. Its population grew from 3,000 people in 1950 to 45,000 people 
today, of which 40 percent are Native Hawaiian and 45 percent are under 
the age of 25. The Wai'anae coast is an economically distressed 
community ranked highest on the island for: households receiving 
financial aid and food stamps; households under the poverty line; and 
rates of unemployment, infant mortality and teen births. Health issues 
are a major concern in the community as Native Hawaiians have the 
highest prevalence of obesity and diabetes in the State. Additionally, 
an estimated 1,000 homeless residents, most of whom are Native 
Hawaiian, live on the Wai'anae coast.
    The Wai'anae Coast Comprehensive Health Center is a Federal Public 
Health Service Community Health Center 330(e) grantee that has served 
the community for the past 32 years. During this time, the Center has 
developed a unique model of healthcare that addresses individual, 
family and community needs through a combination of traditional and 
modern practices.
    The Strengthening Families and Promoting Healthy Lifestyle Project 
developed a healthy culinary training program to promote activities to 
retain and re-establish traditional foods in the family diet. There 
were 939 youth involved in this project. Many Native Hawaiian at-risk 
youth demonstrated improved self-esteem and began integrating the 
traditional culture into their daily lives. For the youth participants 
that were overweight, the project health activities provided a 
comforting and encouraging atmosphere to lose weight. The youth were 
involved in outreach activities like designing the ``KidFit T-Shirt'' 
and creating the Health Center's video public service announcements.
    For the involved families, the project promoted bonding through 
exercise, healthy eating and the revitalization of Kumu Ohana, all of 
which contribute to healthy lifestyles that can prevent diabetes and 
cancer among Native Hawaiians. In addition, the project created 15 jobs 
and leveraged resources were more than $100,000.
    Grantee.--Wai'anae Community Re-Development Corporation
    Project Title.--The Center for Organic Agriculture and 
Sustainability
    Project Funding.--$1,152,476 (includes anticipated continuation 
awards)
    Total ANA Funding.--$1,790,037
    According to the project leaders at Ma'o Organic Farms, Wai`anae 
youth struggle to achieve their socio-economic goals. The statistics 
suggest a bleak future for many Native Hawaiian youth with the State's 
highest rates of teen pregnancy, school suspensions, incidents of 
substance abuse, and juvenile arrests. In addition, Wai`anae is 
recognized as the most food insecure region of Hawaii with Native 
Hawaiians having the highest rates of preventable disease including 
diabetes, heart disease and some cancers. Despite these statistics, 
Wai`anae residents still maintain a rural vision, a willingness to 
perpetuate our community's ``country'' values and to offer hope and 
validation to our `opio of their personal and cultural identities.
    The Center for Organic Agriculture and Sustainability, at Ma'o 
Organic Farms, will positively impact the well-being of Wai'anae youth 
by promoting healthy lifestyles and decreasing the incidence of 
diabetes. The project will engage Native Hawaiian youth in the 
development of organic agriculture and will provide a foundation for 
economic opportunities for youth participants.
    The 3-year project will provide multi-purpose venue for food 
production that will increase commercial efforts of organic farms and 
develop a working base for social enterprise, organic agriculture and 
sustainability that can be replicated in other communities.
    Grantee.--Waipa Foundation
    Project Title.--Waipa Community Kitchen and Business Incubator 
Project
    Project Funding.--$709,260
    Total ANA Funding.--$867,010
    This is a 3-year project to provide a fully-equipped and certified 
commercial kitchen facility that will allow farmers, families, and 
community members to process crops and grow small businesses. The Waipa 
Community Kitchen and Business Incubator will promote a healthy, 
diverse, and sustainable local food economy for the Halele'a-Kilauea 
communities.
    Grantee.--University of Hawaii and Manoa Center (Collaborative 
Project)
    Project Title.--The Hawaii Demonstration to Maintain Independence 
and Employment Project
    Project Funding.--$1,539,002
    The Hawaii Demonstration to Maintain Independence and Employment 
project is a joint endeavor between the Hawaii State Department of 
Human Services, the University of Hawaii at Manoa Center on Disability 
Studies, the Hawaii State Department of Health (DOH), and the Hawaii 
Business Health Council.
    These agencies will engage in a collaborative effort with public 
and private employers, employee groups, and their healthcare providers 
in a comprehensive community-based effort to assist individuals who are 
at high risk of becoming disabled/unemployed as a result of diabetes.
    The partnership enlists promising and emerging practices to 
identify and support persons, ages 18 through 60 years old, with 
potentially disabling and medically determinable physical impairments 
as a result of diabetes.
    Substance Abuse and Mental Health Services Administration (SAMHSA)
    Grantee.--Hawaii Families as Allies--Aiea, HI
    Program.--Statewide Family Networks SM057920
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$70,000
    Project Period.--9/30/2007-9/29/2010
    The Hawaii Statewide Transformation and Empowerment Project (STEP) 
will conduct training, technical assistance, and networking activities 
aimed at substantially increasing the involvement of children and youth 
with emotional, behavioral or mental disorders and their families in 
all levels of Hawaii's system of care. Family members will be supported 
so that they will be able to develop and implement a legislative 
advocacy action plan. STEP will also involve key child-serving 
agencies, including those responsible for child welfare and juvenile 
justice, in an initiative to increase their awareness of and adherence 
to the CASSP values and principles. Another set of activities will 
focus on youth leadership development, focusing on developing and 
implementing a legislative advocacy initiative. HFAA Parent Partners 
will also provide peer supports and mentoring for youth and families in 
their home communities throughout Hawaii.
    Grantee.--Hawaii State Department of Health--Honolulu, HI
    Program.--Child Mental Health Initiative SM057063
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$1,257,281
    Project Period.--9/30/2005-9/29/2011
    Project Ho'omohala (meaning in Hawaiian, ``evolving toward 
maturity'') will develop a system of care to meet transitional needs of 
youth with emotional and/or behavioral challenges, ages 15-21 in the 
Kalihi-Palama community. Culturally and linguistically appropriate 
services will utilize the transition to independence process. Families 
and youth will be active partners in the governing structure and 
evaluation process. The goal of this project is to implement a system 
of care encompassing the transition to independence process for youth 
with emotional or behavioral challenges between the ages of 15-21, 
living in the Kalihi-Palama Community. This goal will be implemented 
through the following actions: (1) establish a Youth Community Center; 
(2) train and assign transition specialists to each youth; (3) develop 
a comprehensive life-skills program; (4) create a range of supportive 
services (e.g., vocational, healthcare); and (5) develop peer mentoring 
services. The applicant is the Hawai'i Department of Health on behalf 
of the governor. Daily management of the grant will be contracted 
through the Center on Disability Studies at the University of Hawai'i. 
The Youth Community Center will be operated by the Susannah Wesley 
Community Center. Wai Aka will provide the young adult support 
services; families and youth will guide the development, 
implementation, and evaluation of this project.
    Grantee.--Hawaii State Department of Health--Honolulu, HI
    Program.--State Data Infrastructure Grants SM058093
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$156,000
    Project Period.--9/30/2007-09/29/2010
    During the project period, AMHD will focus on technical 
implementation of the URS measures, verification of data quality, and 
increased distribution of reports to its Purchase of Service Provider 
network. CAMHD will implement the remaining URS developmental measures, 
but emphasizes building capacity in the knowledge, skills, and 
abilities of personnel to define and distribute customized reports and 
to participate more fully in the DIG network. Upon completion AMHD and 
CAMHD should report on all URS measures, increase distribution of 
system information to stakeholders including State council, increase 
integration of the available information into planning and decision 
making.
    Grantee.--Hawaii State Department of Health--Honolulu, HI
    Program.--Mental Health Transformation State Incentive Grants 
SM057457
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$2,190,500
    Project Period.--9/30/2006-9/29/2011
    The goal of this mental health systems transformation project is to 
create a sustainable, fully integrated, comprehensive statewide mental 
health plan and to implement a system-wide transformation process over 
the course of a 5-year period. Staffing for this grant can be 
conceptualized as a model of concentric circles whereby the 
transformation work group is at the center surrounded by mental health 
stakeholders coming together in different partnerships to breathe life 
into the transformation. The next ring supporting these activities is a 
technical assistance group and project evaluation team comprised of 
grant-funded staff and in-kind University of Hawaii staff who will 
assist the transformation work group and stakeholders in tasks such as 
planning, implementation, program evaluation and workforce development. 
Finally, the outer ring of the model is the community-at-large whose 
acceptance of mental health as an integral part of overall well being 
is required to bring about full transformation of the system. Hawaii, 
because of its diversity, is in a unique position to develop effective 
models of service delivery and care that address the needs of the 
growing multi-cultural population across the country. Hawaii is 
committed to seizing the opportunity created by national and State 
strengths and resources; directing and focusing the efforts of all 
sectors to address priority mental health needs; building on successes 
to move past an era of Federal court mandates; and realizing the vision 
of quality mental healthcare across all of Hawaii's communities for the 
entire population.
    Grantee.--United Self-Help--Honolulu, HI
    Program.--Statewide Consumer Network SM056346
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$70,000
    Project Period.--9/30/2004-9/29/2010
    Bridging Islands will foster and sustain consumer networks within 
each neighbor island, collaborate with existing networks and strengthen 
pee mentors. Each goal will address county based needs within each area 
with specific outcomes. The process will increase State capacity to 
support effective mental health services while strengthening peer 
mentors and sustaining neighbor island consumer network development. 
Collectively, the county and consumers will evaluate lessons learned 
and incorporate recommendations into the next iteration of 
transformation activities.
    Grantee.--Hawaii State Department of Health--Honolulu, HI
    Program.--Youth Suicide Prevention and Early Intervention--
Cooperative Agreement State-Sponsored SM058397
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$500,000
    Project Period.--9/30/2008-9/29/2011
    The Injury Prevention and Control Section (IPCS) of the DOH is 
proposing to implement the Hawaii Gatekeeper Training Initiative (HGTI) 
to reduce completed and attempted suicides among youth ages 10-24. This 
will be accomplished through training adult gatekeepers in key agencies 
to recognize and respond to youth who are at risk for suicide. This 
will also increase youth access to trained gatekeepers in Hawaii. The 
HGTI will use three training curricula: Applied Suicide Intervention 
Skills Training (adults), SafeTALK (police officers), and Signs of 
Suicide (youth). IPCS will leverage the grant resources by 
incorporating gatekeeper training in three systems that already impact 
significant numbers of youth in both school and community settings. 
These agencies and their programs include: Department of Education 
(Peer Education Program), and School-Based Behavioral Health), the 
Department of Health Alcohol and Drug Abuse Division (agencies 
contracted to provide treatment services in their Adolescent Substance 
Outpatient School-Based Treatment Program), and prevention services in 
their Youth Substance Prevention Partnerships Initiative), and the 
Honolulu Police Department (Emergency Psychological Services/Jail 
Diversion Program). The HGTI will accomplish two goals: (1) enhance 
State level infrastructure for youth suicide prevention efforts, and 
(2) enhance youth suicide prevention efforts in three systems: Public 
School, Alcohol/Substance Abuse Treatment and Prevention, and Law 
Enforcement.
    Center for Substance Abuse Prevention (CSAP)
    Grantee.--Parents and Children Together--Honolulu, HI
    Program.--Drug Free Communities SP012968
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$100,000
    Project Period.--9/30/2005-9/29/2010
    The grantee will: (1) reduce substance abuse among youth and over 
time, among adults by addressing factors in the community that increase 
the risk of substance abuse and promote factors to minimize the risk of 
substance abuse; (2) establish and strengthen citizen participation and 
collaboration among communities, nonprofit agencies, and Federal, 
State, local, and tribal governments to support community efforts to 
deliver effective substance use prevention strategies for youth; (3) 
use the Strategic Prevention Framework of evidence based prevention 
strategies to assess needs, build capacity, plan, implement and 
evaluate community prevention initiatives; and (4) assess and report on 
the effectiveness of community prevention initiatives to reduce age of 
onset of any drug use, frequency of use in the past 30 days, increased 
perception of risk or harm, and increased perception of disapproval of 
use by peers and adults.
    Grantee.--Waipahu Community Association--Waipahu, HI
    Program.--Drug Free Communities SP011543
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$100,000
    Project Period.--9/30/2005-9/29/2009
    The grantee will: (1) reduce substance abuse among youth and, over 
time, among adults by addressing the factors in a community that 
increase the risk of substance abuse and promoting the factors that 
minimize the risk of substance abuse; and (2) establish and strengthen 
community anti-drug coalitions.
    Grantee.--Coalition For A Drug-Free Hawaii--Honolulu, HI
    Program.--Drug Free Communities SP014887
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$125,000
    Project Period.--9/30/2008-9/29/2013
    The grantee will: (1) reduce substance abuse among youth and over 
time, among adults by addressing factors in the community that increase 
the risk of substance abuse and promote factors to minimize the risk of 
substance abuse; (2) establish and strengthen citizen participation and 
collaboration among communities, nonprofit agencies, and Federal, 
State, local, and tribal governments to support community efforts to 
deliver effective substance use prevention strategies for youth; (3) 
use the Strategic Prevention Framework of evidence based prevention 
strategies to assess needs, build capacity, plan, implement and 
evaluate community prevention initiatives; and (4) assess and report on 
the effectiveness of community prevention initiatives to reduce age of 
onset of any drug use, frequency of use in the past 30 days, increased 
perception of risk or harm, and increased perception of disapproval of 
use by peers and adults.
    Grantee.--Coalition For A Drug-Free Hawaii--Honolulu, HI
    Program.--Sober Truth on Preventing Underage Drinking Act Grants 
SP015489
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$50,000
    Project Period.--9/30/2008-9/29/2012
    The purpose of the Sober Truth on Preventing Underage Drinking 
(STOP) Act grant program is to prevent and reduce alcohol use among 
youth in communities throughout the United States. The STOP Act grant 
program will encourage existing local community coalitions to develop, 
assess, and implement effective strategies to prevent and reduce 
underage drinking. Strategies may include: changing local attitudes and 
norms, and re-evaluating existing laws and policies. (1) Grantee must 
participate in national evaluation activities of the STOP grant 
program. (2) STOP Grantees must use the Strategic Prevention Framework 
(SPF), a five-step evidence based process for community planning and 
decision-making. The five step process includes: needs assessment, 
capacity building, planning, implementation and evaluation. (3) STOP 
grantees must plan and implement a comprehensive approach inclusive of 
multiple strategies as emphasized in the 2007 Surgeon General's Call to 
Action to prevent and Reduce Underage Drinking located online at: 
http://www.surgeongeneral.gov/topics/underagedrinking/call--to-- 
action.pdf Emphasis should be given to environmental strategies that 
incorporate prevention efforts aimed at changing or influencing 
community conditions, standards, institutions, structures, systems and 
policies. In addition, grantees must select strategies that lead to 
long term outcomes. (4) STOP grantees must enhance, not supplant, 
effective local community initiatives for preventing and reducing 
alcohol use among youth. For current Drug Free Community grantees, STOP 
ACT foods can not be used to supplant or replace activities that are 
presently being supported by Drug Free Community funds, and, separate 
DFC and STOP ACT accounting systems must be maintained for the purposes 
of reporting.
    Grantee.--Kulia Na Mamo--Honolulu, HI
    Program.--HIV/Strategic Prevention Framework SP013382
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$254,320
    Project Period.--9/30/2005-9/29/2010
    The project targets Asian and Pacific Islander male-to-female 
transgender and men who have sex with men, age 27 and older. Many of 
the former are ex-incarcerated, and both groups, which make up the Mahu 
(two spirits) community in Hawaii, are minority populations at highest 
risk for HIV (i.e., of all API diagnosed with AIDS, over 65 percent are 
MSM, which includes transgender). From our own surveys of over 100 
transgender clients, more than 60 percent are ex-inmates, 54 percent 
are sex industry workers and more than 30 percent are crystal meth 
users. 50 percent of the participants will be re-entry. Interventions 
will be provided to approximately 150 participants a year. The project 
is divided into two parts: (1) Capacity Building.--The application will 
spend the first 6 to 9 months of the first year establishing a 
workgroup or task force that will conduct a community needs assessment. 
The task force will be made up of the following agencies: Department of 
Health STD/AIDS Prevention Branch; Department of Health Disease Control 
and Outbreak Division; Life Foundation, an AIDS service organization; 
Drug Addiction Services of Hawaii, Inc.; Coalition for a Drug-Free 
Hawaii, a prevention agency; Hina Mauka, a treatment/prevention agency; 
Department of Public Safety; Hawaii Cares--the coalition of Ryan White 
providers; and other agencies. The needs assessment will be the basis 
for a strategic plan to be implemented after approval from SAMHSA. 
During this initial period Kulia Na Mamo will develop memoranda of 
agreement with treatment agencies, the Department of Public Safety, and 
others with which to establish linkages to care. Kulia will attend 
meetings of the HIV Community Planning Group, work with the Jade Ribbon 
Campaign for hepatitis B testing, and coordinate activities related to 
hepatitis C with the hepatitis C coordinator at the Department of 
Health STD/AIDS Prevention Branch. (2) Implementation, Monitoring, and 
Evaluation.--The proposal follows interventions endorsed by the CDC 
and/or SAMHSA: Prevention.
    Grantee.--Hawaii State Office of the Governor--Kaplei, HI
    Program.--Strategic Prevention Framework State Incentive Grants 
SP013944
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$2,093,000
    Project Period.--9/30/2006-9/29/2011
    The purpose of Hawaii's SPF State Incentive Grant (SIG) is to 
improve the quality of life of our citizens by preventing and reducing 
the abuse and dependence on alcohol and other drugs among people of all 
ages. The SPF SIG will enable Hawaii to (a) support a coordinated and 
comprehensive approach to substance abuse prevention; (b) ensure that 
prevention is the first line of defense against illegal drug use and 
underage drinking; (c) establish effective alcohol and other substance 
abuse prevention efforts that are evidence-based, culturally 
appropriate, and long term; and (d) minimize duplicative efforts among 
partnering agencies, while promoting coordination and identifying gaps 
in data and services.
    Grantee.--Five Mountains Hawaii--Kamuela, HI
    Program.--Drug Free Communities SP012310
    Congressional District.--HI-02
    Fiscal Year 2008 Funding.--$125,000
    Project Period.--9/30/2005-9/29/2013
    The grantee will: (1) reduce substance abuse among youth and, over 
time, among adults by addressing the factors in a community that 
increase the risk of substance abuse and promoting the factors that 
minimize the risk of substance abuse; and (2) establish and strengthen 
community anti-drug coalitions.
    Grantee.--Hamakua Health Center--Honokaa, HI
    Program.--CSAP 2008 EARMARKS SP014596
    Congressional District.--HI-02
    Fiscal Year 2008 Funding.--$95,305
    Project Period.--9/01/2008-8/31/2009
    This project is designed to improve access for the low-income and 
uninsured population and improve the coordination of care between 
agencies in each of the Health Center service areas, resulting in 
greater accessibility to support services and increased referral 
follow-through for patients with risk for and active substance abuse.
    Center for Substance Abuse Treatment
    Grantee.--Hawaii State Department of Health--Honolulu, HI
    Program.--Access to Recovery TI019437
    Congressional District.--HI-01
    Fiscal Year 2008 Funding.--$2,750,000
    Project Period.--9/30/2007-9/29/2010
    The Hawaii Access to Recovery (HI-ATR) program targets the adult 
population of child welfare families for the Hawaii Island of Oahu 
(City and County of Honolulu). ``Ice'' is the major factor behind 
Hawaii's explosion of child protection cases, in which Native Hawaiians 
represent more than 50 percent of Child Protective Services cases and 
other Asian-Pacific Islanders are also overrepresented. Hawaii is a 
unique State with (1) the greatest proportions of methamphetamine or 
``ice'' abuse in the Nation, (2) inadequate and fragmented treatment 
resources and significantly limited recovery support services. HI-ATR 
Project will introduce a system of vouchers managed electronically 
through a 42 CFR, Part 2 and HIPAA-compliant web-based information 
technology (IT) system to improve access to treatment and, subsequent 
to adequate assessment and referral to an appropriate level of care, 
genuine independent client choice of service providers, including faith 
and community-based organizations (FCBOs), especially those that have 
not previously received public funding. This project will not only 
provide the critically needed additional capacity to address Hawaii's 
ice epidemic but will also contribute significantly to strengthening 
existing families and healing and reunifying shattered Asian/Pacific 
Island families, thus ensuring the preservation of the unique heritage 
and traditions of Hawaii's peoples.
                             practitioners
    Question. Given the need to create practice incentives for 
practitioners that are aligned with the health reform legislation being 
proposed (such as cost-effective practice, adoption of quality 
measures, and use of practice guidelines), what medical legal 
protections can be extended to practitioners on a Federal level such 
that the practice of defensive medicine is eliminated?
    Answer. The President has stated that he understands that some 
doctors feel that they are looking over their shoulders out of fear of 
lawsuits and often order more tests and treatment to avoid being 
legally vulnerable. He does not advocate caps on malpractice awards, 
which could be unfair to people who've been wrongfully harmed, but he 
does think we should explore a range of ideas to put patients first 
while letting doctors focus on practicing medicine. There have been a 
number of proposals offered in recent years to reduce lawsuits and 
promote patient safety, from plans to expand the use of ``Sorry Works'' 
systems (early disclosure and apology-based mediation) as then-Senator 
Obama introduced in 2005, to proposals to encourage broader use of 
evidence-based guidelines as Senator Wyden and others have supported. 
There are many ideas out there and the President and I want to work 
with you.
    Question. Given the shortage of rural practitioners across America 
and the limitations associated with recruitment and retention of 
practitioners to rural Hawaii, what incentives can be established to 
encourage rural training of practitioners, including needed 
specialists?
    Answer. Effective health action requires an adequately staffed, 
highly skilled, diverse and interdisciplinary workforce prepared to 
address health challenges of the 21st century. In HRSA, the budget 
expands loan repayment and scholarship programs for physicians, nurses, 
and dentists who are committed to practicing in medically underserved 
areas. Additionally, funding will enhance the capacity of nursing 
schools, increase access to oral healthcare through dental workforce 
development grants, target minority and low-income students, and place 
an increased emphasis on ensuring that America's senior population gets 
the care and treatment it needs.
    The administration also provided additional funds for the Indian 
Health Service (IHS) to cover the rising cost of tuition impacting 
scholarship and loan repayment programs. These programs help IHS 
compete with other public and private sector employers and bring needed 
healthcare professionals to remote, rural reservations. In addition, 
IHS provides grants to universities to train American Indians and 
Alaska Natives to return to their communities as healthcare 
professionals. We believe these programs will help ease the shortage of 
rural practitioners over time.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
                          healthcare workforce
    Question. One area of concern that I believe must be addressed is 
the shortage of healthcare providers. And as the baby boomers retire, 
the problem is only going to get worse.
    I have had a number of roundtables throughout my home State of 
Washington on this issue. And I know that what we're seeing in 
Washington State is similar to what is going on across the country. The 
shortage of doctors, nurses, and other healthcare providers is one of 
the most serious workforce challenges our country faces.
    And as we are working on healthcare reform, I believe it is 
important to keep in mind that affordable care will not be possible 
without access to a healthcare provider. In addition, this workforce 
shortage is only going to get worse as we move to cover more people.
    What do you see as our best tools to address this problem within 
the regular appropriations process?
    Answer. The National Health Service Corps provides a venue to 
incentivize more primary care providers across the spectrum (including 
dentistry, nursing, and mental health) to serve in underserved areas. 
This program can be targeted towards people at the end of their 
education, to address short-term as well as long-term workforce needs. 
Expanding nurse faculty loan programs will address a critical 
bottleneck in the education of new nurses to address the current and 
looming nursing shortage. Providing additional funds for scholarships 
and loan repayment programs for students--including those targeted to 
improve diversity--can also have a dramatic impact on ensuring an 
effective workforce.
    The fiscal year 2010 request includes over $1 billion supporting a 
wide range of programs to strengthen and support our Nation's 
healthcare workforce. These investments will expand loan repayment and 
scholarship programs for physicians, nurses, and dentists who are 
committed to practicing in medically underserved areas. Additionally, 
this funding will enhance the capacity of nursing schools and increase 
access to oral healthcare through dental workforce development grants.
    Question. How do you think we can address this problem within 
healthcare reform?
    Answer. We can and should build on existing workforce programs such 
as the National Health Service Corps and title VII and title VIII. 
These programs need to be modernized to better address a changing 
healthcare environment. We should also encourage innovation in 
telemedicine, health IT, and other avenues to improve practice 
environments which will enhance workforce productivity and retention.
                             home visiting
    Question. I am so pleased that President Obama and your agency are 
focusing on Home Visiting as an effective program to ensure that 
children and families receive the supports and information they need 
for healthy development, child abuse prevention, safety, and 
preparation for education. As you know, I introduced the Education 
Begins at Home Act with Senators Clinton and Bond earlier this year, 
which focuses on promoting high-quality, effective home visiting 
programs that improve the health, development, and school readiness of 
children ages 0 to 5.
    I think it's necessary to highlight a few key components to any 
effective home visiting program to ensure the best outcomes for 
children across the country. It is critical that any program is 
evidence-based, which I know is important you and the President as 
well. Another important component is providing support not only for 
health outcomes, but also well being and school readiness, in a 
continuum of home visiting care. When all of these outcomes are met, 
home visiting can reduce the need for special education services, help 
families raise their monthly earnings, reduce child abuse, prepare 
children to succeed in pre-K or kindergarten, and assist with stronger 
birth outcomes, among many other benefits.
    Do I have your commitment to work towards a model that provides 
significant support for the continuum of home visiting programs and 
models, as long as they are evidence-based, in order to meet the varied 
needs of young children and their families across the country?
    Answer. Yes, the Home Visitation initiative will give priority to 
models that have been rigorously evaluated and shown to have positive 
effects on critical outcomes for families and children. Additional 
funds will support promising programs, such as programs based on models 
with some research evidence of effectiveness and adaptations of 
previously evaluated programs.
                    title x family planning program
    Question. In a report released last week by the National Academy of 
Sciences Institute of Medicine, family planning was described as ``one 
of the most significant public health achievements of the 20th 
century.'' The report goes on to say that family planning has resulted 
in improvements in health, economic and social well-being.
    The Institute's study also cites that ``funding for the title X 
(Ten) Program has not kept pace with a number of factors including: 
inflation; increased costs of contraceptives, great numbers of people 
seeking services; or rising insurance costs.''
    Do you agree with the assessment that family planning funding has 
not kept pace with these factors?
    Answer. The title X program has been able to maintain access to 
services for millions of individuals who need family planning services 
each year through maximizing the resources provided in the 
appropriations each year. Through the program's training authority, 
training has been provided to title X administrators and clinical 
providers to encourage the most efficient utilization of resources 
while maintaining quality. In addition, title X providers have been 
encouraged to use the 340B Drug Pricing Program, cooperative purchasing 
programs, and other cost-savings mechanisms to cut costs where 
possible.
    Question. Do you think that a significant increase in funding for 
the title X program will help serve the ever increasing number of 
American families who are unable to afford the most basic of healthcare 
services?
    Answer. The fiscal year 2010 budget provides an increase that would 
enable the title X program to serve a greater number of low-income 
individuals who are currently not receiving services. Currently, 4 in 
10 poor women of reproductive age have no insurance coverage, public or 
private. The Title X Family Planning Program requires that services be 
provided to all who want and need them, with a priority for services to 
individuals from low-income families. Title X-funded centers are an 
important source of preventive healthcare to nearly 5 million women 
each year, more than 90 percent of whom have family incomes at or below 
200 percent of the Federal poverty level. At least 64 percent of those 
served by title X centers have no insurance coverage for primary 
healthcare, public or private. According to the most recent National 
Survey of Family Growth data, a majority of women who obtain care at a 
family planning center consider it their usual or primary source of 
healthcare. It is estimated that only 54 percent of women in need of 
publicly subsidized contraception received those services in 2006, with 
title X providing services to half (27 percent) of these women.
    In addition to the contraceptive services provided under the title 
X program, title X-funded family planning centers provide a number of 
related preventive health services that millions of poor and uninsured 
individuals would likely not otherwise receive. For instance, in 2007, 
title X-funded health centers provided almost 2.5 million Pap tests; 
2.4 million breast exams; 5.4 million tests for sexual transmitted 
diseases that if left untreated, may lead to infertility; and, 764,126 
confidential HIV tests. In addition, it is estimated that nearly 
970,000 unintended pregnancies were averted through the services 
provided by title X-funded centers in 2007.
         u.s. domestic refugee program and the economic crisis
    Question. Historically, the United States has been the world leader 
in providing protection and assistance to refugees both internationally 
through humanitarian assistance and domestically by resettling refugees 
to the United States. Unfortunately, the resettlement program now finds 
itself on the brink of crisis.
    The Office of Refugee Resettlement (ORR) within the Department of 
Health and Human Services was established in 1980 to assist refugees 
admitted by the United States in obtaining economic self-sufficiency. 
Since then, ORR's mission has grown to include assisting numerous other 
vulnerable populations in the United States, among them trafficking 
victims, torture victims, Cuban/Haitian Entrants, Indochinese Parolees, 
Iraqi and Afghan Special Immigrants, and unaccompanied alien children. 
Unfortunately, ORR's budget has not kept up with its growing mission, 
the changing characteristics of the populations it now serves, and the 
costs and needs of resettling today's refugees. Coupled with chronic 
under funding, the challenges connected to the current economic crisis 
have placed the resettlement program in peril.
    Even before the current economic recession, resettlement agencies 
have been struggling to meet the needs of refugees, and a number of 
agencies had to close down offices across United States. Now refugees 
are commonly experiencing great difficulty finding work and paying rent 
and other basic household needs. Agencies that have relied on private 
funding, donations and the help of our communities to overcome the 
insufficient funding are struggling to secure resources in the current 
environment. The situation is critical; the resettlement program needs 
immediate reform in key areas to maintain the success it has achieved 
in the past and to match our international commitment to provide 
protection to refugees.
    How is ORR planning to respond to the consequences of the economic 
crisis on the resettlement program and ensure adequate assistance to 
refugees and other vulnerable populations while they work toward 
integration and self-sufficiency? What steps will ORR take in the 
future to better respond to emergency situations?
    Answer. ORR provides a host of supports to refugees to assist them 
with achieving economic self-sufficiency and integration, including 
cash and medical assistance, case management, and employment services. 
The current economic conditions have made it more difficult for 
refugees to gain employment quickly, even for those in the Matching 
Grant program, which historically has been the most successful method 
for placing refugees into employment quickly. As a result, refugees and 
other eligible populations are accessing cash and medical assistance 
for longer periods of time, often for the full 8 months for which they 
are currently eligible. The number of refugees also is on the rise, 
and, for the first time since 2001, the number of arrivals appears to 
be approaching the refugee ceiling set by the State Department. For 
these reasons, the fiscal year 2010 budget request includes $337 
million for refugee transitional and medical services, $55 million more 
than the amount appropriated in fiscal year 2009. ORR will closely 
monitor arrivals and benefit access, and provide updated cost estimates 
to Congress as necessary. The Administration is also keenly interested 
in examining ways to improve refugee resettlement programs, especially 
in light of the current economic crisis.
                      emergency housing assistance
    Question. The economic crisis is negatively impacting refugees 
across the country, challenging their successful integration into our 
communities and making homelessness a real threat to many refugee 
families. Due to rising living costs and a shortage of jobs, newly 
arriving refugees are finding it increasingly difficult to secure and 
maintain employment and housing. As a result, some refugee families are 
not able to find jobs and meet the cost of rent, and are thus facing 
eviction and homelessness. Several recent news stories illustrate the 
challenges refugees are facing with housing and homelessness across the 
country.
    A number of federally funded programs administered by local refugee 
resettlement agencies assist refugees in securing employment and 
housing. These programs have been highly effective in helping refugees 
achieve early self-sufficiency through employment. However, refugees 
are only eligible for benefits and services for a maximum of the first 
8 months in the United States. In the current economic climate it can 
take refugees longer than 8 months to secure employment which would 
enable them to afford basic housing. Additionally, many of those 
refugees who have been able to secure employment have been recently 
laid off and have lost their source of income. In most of these cases 
refugees have not worked long enough to qualify for unemployment 
benefits.
    What steps will you take to address the housing needs of resettled 
refugees and other vulnerable populations served by the ORR to prevent 
evictions and homelessness for these populations?
    Answer. The President's budget request is intended to address many 
refugee needs. With respect to risk of homelessness, refugees can 
access a variety of homelessness prevention and assistance programs 
through the U.S. Department of Housing and Urban Development (HUD) or 
State or county housing programs. HHS Refugee Resettlement funds have 
not been targeted to homeless services, beyond the provision of cash 
assistance and some limited use of social services funds.
    Question. How are you planning to address the housing needs of 
refugees that have been in the United States for more than 8 months, 
are not longer receiving cash assistance and have not achieve self-
sufficiency?
    Answer. The President's budget request is intended to address many 
refugee needs. With respect to risk of homelessness, refugees can 
access a variety of homelessness prevention and assistance programs 
through the U.S. Department of Housing and Urban Development or State 
or county housing programs. HHS Refugee Resettlement funds have not 
been targeted to homeless services, beyond the provision of cash 
assistance and some limited use of social services funds.
    Question. The cash assistance refugees receive is determined by 
welfare rates in the States they reside in. In almost all cases (some 
stats would be nice), the level of assistance is below poverty line and 
does not even cover rent. How will you ensure that refugees are not 
resettled into an immediate crisis situation, critically dependent on 
securing a job in order to stay in their homes?
    Answer. Refugee populations are exempted from any bars restricting 
legal permanent resident aliens from accessing public benefits such as 
TANF, Medicaid, and SSI, and may therefore access a number of services 
apart from cash assistance provided by ORR, if they are otherwise 
eligible. In addition, refugees may access services provided through 
ORR's Refugee Social Services and Targeted Assistance funds, including 
adjustment services, English language instruction, interpretation and 
translation services, day care for children, citizenship and 
naturalization services, etc. The goal of these services is to maximize 
refugees' prospects for self-sufficiency.
    Question. Looking forward to the future, how ORR will ensure that 
refugees and other vulnerable people it serves have a safety net strong 
enough to prevent them from losing their homes while they look to 
secure employment?
    Answer. Refugees can access a variety of homelessness prevention 
and assistance programs through HUD or State and county housing 
programs. They are also generally eligible for public benefits such as 
TANF, Medicaid, and SSI. ORR's mandate is to provide services such as 
cash assistance, medical assistance, case management, and employment 
services. The goal of these services is to maximize refugees' prospects 
for self-sufficiency, which will hopefully mitigate any risk of acute 
problems such as homelessness.
             assisting refugees to achieve self-sufficiency
    Question. The resettlement program has as a main objective to 
assist refugees to obtain self sufficiency in a short period of time. 
The economic crisis has made it more difficult for refugees to achieve 
this goal. While most refugees have typically found employment quickly, 
the worsening economy has made this process lengthier and more 
difficult.
    The current job market makes programs that provide employment 
services all the more critical. One of these programs is the Voluntary 
Agency Matching Grant program. This program enables refugees and other 
eligible persons to become self-sufficient within 4 to 6 months from 
the date of their arrival in the United States without resorting to 
Federal and State welfare programs. The program leverages public funds 
with private donations at a 2:1 ratio, requiring private voluntary 
agencies to provide one dollar of private, nongovernmental resources 
for every $2 that the Federal Government contributes. Nearly 80 percent 
of participants in fiscal year 2008 achieved self-sufficiency. Even 
though the outcomes have been impacted by the current economic crisis, 
Matching Grant continues to be the most successful program helping to 
place refugees in jobs in a 4- to 6-month period.
    Currently the program serves approximately 27,000 individuals, the 
same number of individuals that were served by the program in fiscal 
year 2000. This equals roughly 30 percent of those who could benefit 
from the program. The program has also been expanded to serve not only 
refugees, asylees, Cuban/Haitian entrants, but also Iraqi and Afghan 
Special Immigrant Visas (SIVs) holders and victims of trafficking. The 
Iraqis arriving as refugees or SIVs are in most cases highly educated 
and experienced and would therefore be most appropriately served 
through the Matching Grant (MG) program. Without increased ORR 
resources, additional places in the MG program will not be available.
    As the expression of the public-private partnership the Voluntary 
Match Grant Program is most successful program helping refugees find 
jobs. Are you planning to expand the program by providing more 
resources allowing access for more refugees and other vulnerable 
populations?
    Answer. Under the fiscal year 2010 budget request, the Matching 
Grant program will be funded at the same level as fiscal year 2009.
    Question. Many Iraqis who arrived as SIVs or refugees are highly 
educated and are facing challenges to achieve self-sufficiency and to 
find suitable jobs. In the past the MG program provided better served 
populations with those characteristics. What role do you envision for 
the MG program for highly educates refugees, such as the case of 
Iraqis?
    Answer. The Matching Grant program is indeed ideally suited for 
refugees with good employment prospects, and Iraqi SIVs and refugees 
are generally excellent candidates. To the extent that funded 
enrollment slots are available in the area of resettlement, highly 
educated refugees or SIVs may elect to enroll in the Matching Grant 
Program.
    Question. Highly educated refugees often have to accept the first 
job available to be able to pay for their basic needs. Such a job may 
not be inappropriate for their skill level, which leads to frustration 
on their part and a waste of talent and potential for the American 
society. Do you plan to initiate and fund any programs that would help 
highly educated refugees with years of professional experience secure a 
job appropriate for their skills?
    Answer. While there are no special programs that target skilled 
refugees and no plans to create any expanded assistance to refugee 
professionals, ORR does have an existing grant with a technical 
assistance provider looking at professional recertification issues. 
Most activities for skilled professionals are provided at the 
discretion of local refugee social services providers as part of their 
broader employment services assessment and activities related to each 
Individual Employment Plan. ORR has been working with the Department of 
Labor to identify resources available to refugee professionals through 
the Employment and Training Administration's One Stop Centers.
    Question. The structure of the U.S. resettlement program and its 
emphasis on self-sufficiency is often too rigid to account for 
additional challenges faced by many more vulnerable resettled refugees. 
Many, for example, have been recently widowed or disabled and will be 
much less likely to find employment within the program's limited time 
frame. What changes can be made to account for the special 
circumstances of certain vulnerable refugees to ensure that they are 
able to achieve self-sufficiency in safety and dignity?
    Answer. ORR has no special programs for individuals with 
disabilities or other needs, but ORR providers have broad flexibility 
to work with disabled refugees, and ORR funds may be used to pay for 
these individuals' medical and mental health costs if individuals are 
not eligible for Medicaid. ORR providers also make referrals to (SSI) 
and other benefits and services for refugees who meet disability 
definitions in title XVI of the Social Security Act. Disabled refugees 
who are awaiting adjudication of SSI applications may receive Refugee 
Cash Assistance for up to 8 months while their applications are 
processed. Finally, ORR is taking further steps to improve the self-
sufficiency prospects of disabled refugees, including early discussions 
with the HHS Office on Disability regarding employment for disabled 
refugees.
                                 ______
                                 
                Questions Submitted by Senator Jack Reed
               low income home energy assistance program
    Question. As you know, the Low Income Home Energy Assistance 
Program (LIHEAP) was funded at $5.1 billion for the first time in 
fiscal year 2009, providing much needed assistance to millions of 
Americans at a time of economic uncertainty. Although some energy costs 
have temporarily stabilized, the economic standing of millions of 
Americans has worsened. Like funding for food stamps and unemployment 
insurance, LIHEAP provides a significant multiplier effect that is 
important in helping to bring us out of this recession.
    While the President's budget request of $3.2 billion is greater 
than any request made to Congress in the past, it is still far below 
last year's appropriation. The National Energy Assistance Directors' 
Association found that a reduction in LIHEAP funding to $3.2 billion 
could result in more than 1.5 million households being dropped from the 
program, and the average grant for families left in the program being 
cut by $70. While I appreciate the fact that this Administration has 
proposed creating a mandatory contingency fund for LIHEAP when prices 
spike, that funding is dependent on price volatility and will produce 
on $450 million in funding on average per year. We need to have robust 
funding in the base program.
    As you know, the congressional budget resolution matches the 
President's request of $3.2 billion for LIHEAP for fiscal year 2010, 
but would also accommodate an extra $1.9 billion through a 
discretionary cap adjustment that maintain funding at the $5.1 billion 
level. Would you support LIHEAP funding at the $5.1 billion allowed 
under the budget resolution? Will you also work to fully fund this 
program in future budgets?
    Answer. Energy prices are volatile making it difficult to match 
funding to need. Fiscal year 2009 LIHEAP funding ($5.1 billion) was 
provided when energy prices were at their peak (oil at $124 per barrel 
in the second quarter of 2008). Oil prices subsequently declined 
significantly as did Energy Department estimates of average home 
heating costs. The administration proposed the mandatory trigger 
mechanism to address volatility in energy prices. Under this proposal, 
mandatory funding would be provided in response to quarterly energy 
price increases. If oil and gas prices in the fourth quarter of 2009 
exceed peak 2008 prices by just 1.8 percent, total LIHEAP funding of 
$5.1 billion would be provided in fiscal year 2010 through a 
combination of the trigger ($1.9 billion) and the discretionary budget 
request ($3.2 billion).
                             immunizations
    Question. Immunizing our country's children--and adults--has been a 
priority for me throughout my tenure in Congress. I was particularly 
pleased that the Economic Recovery Act contained an additional $300 
million over the next 2 years for immunizations for the uninsured and 
underinsured. But, once that funding runs out, the baseline funding 
that the President proposed would likely fall back to $500 million. As 
you may know, I have been joined by 17 of my colleagues in supporting 
more than $800 million in baseline funding to immunize this population. 
Have you given any thought to how you will fill the financial void 
after next year should funding fall back to $500 million?
    Answer. Historically, vaccines are one of the most successful and 
cost effective public health tools for preventing serious disease and 
death. The Center for Disease Control and Prevention's (CDC) 
immunization investments save lives and dollars by providing 
individuals and communities with a strong level of protection from 
vaccine-preventable diseases. The Recovery Act 317 section funding 
provided a historic opportunity to leverage section 317 immunization 
investments by augmenting existing public health capacity and federally 
purchased vaccines.
    In accordance with the Recovery Act, CDC is investing these funds 
in one-time efforts that will have the most health impact. The Recovery 
Act funding CDC received is being used to make vaccines available to 
more children, adolescents, and adults; help health departments learn 
how to improve their access to insurance reimbursement; increase 
awareness and provider education about immunization; and strengthen the 
evidence base for immunization policies and programs. These investments 
will have long-term benefits beyond the life of the funding by 
increasing the number of people vaccinated, providing immunization 
tools and resources for parents and healthcare providers, and assessing 
the impact of recently recommended vaccines to inform national vaccine 
policy.
                         pandemic preparedness
    Question. According to testimony before this panel on April 30, I 
understand that States have purchased only 23 million of the 31 million 
courses of antiviral treatments called for under the National Strategy 
on Pandemic Influenza. Rhode Island is only equipped with 10.5 percent 
of its allocation. Given the potentially urgent need for these 
medications, how does the Department of Health and Human Services plan 
to address the shortfall in State stockpiling efforts and prevent 
illness?
    Answer. Currently, State stockpiles have 24.5 million treatment 
courses. The Department is considering extending the Federal subsidy 
program for State antiviral stockpiling beyond the current end date of 
September 1, 2009, to allow States the ability to purchase up to an 
additional 4 million treatment courses during the fall and upcoming flu 
season necessitated by the current swine flu pandemic. States have 
already received 11 million treatment courses collectively from the 
Federal influenza antiviral drug stockpile in early May 2009 as a 
response measure for the H1N1 virus outbreaks in the United States 
These treatment courses pushed out to States from the Federal stockpile 
have now been added to each respective State stockpile total. For 
example, to use the case of Rhode Island, the Federal push of 25 
percent of their pro rata Federal allotment now added to their State 
stockpile (representing about 40,000 treatment courses) brings the new 
total to about 52,000 treatment courses. Therefore, Rhode Island is now 
equipped with about 46 percent of its State stockpile program pro rata 
allocation. Furthermore, the 11 million treatment courses in total 
pushed out from the Federal stockpile will also be replenished in full 
and that process is now underway. In addition, the Federal stockpile, 
which will be replenished to the initial 44 million treatment course 
level, will again be available in full for distribution to States 
should the need arise.
                          healthcare workforce
    Question. The Senate and the House are poised to have a meaningful 
debate on healthcare reform. With reform, we must also ensure that 
there is a workforce to adequately address the expected increase in 
patients. I am aware that the Economic Recovery Act contained an 
additional $200 million for title VII health professions programs. 
However, I am concerned that even with this increase, the funding level 
in the budget would not adequately address workforce shortages for 
years to come--especially in light of reform. In light of this, nearly 
half of my colleagues in the Senate have joined me in supporting $330 
million for title VII health professions programs. How did the 
administration account for the potential effects of healthcare reform 
in budgeting for an adequate primary care workforce?
    Answer. We are aware that with the expansion of coverage comes the 
need to provide primary care and other health services, particularly in 
areas that are currently underserved. Investments through the Recovery 
Act will assist in expanding and improving the efficiency of our 
provider workforce. We look forward to working with Congress to address 
the workforce needs that will arise from comprehensive health reform
                      conquer childhood cancer act
    Question. Last year, Congress passed and President Bush signed the 
Caroline Pryce Walker Childhood Cancer Act. Among other provisions, 
this law requires CDC to collect information on the causes, treatments, 
and effects of childhood cancer within weeks of learning of this 
information in a comprehensive childhood cancer registry. 
Individualized and aggregate data would dramatically enhance research 
initiatives and open the door for new, successful treatment options for 
patients. The CDC Cancer Registry line has been flat funded for years. 
Given the administration's effort to spur health innovation and 
research, how will you capitalize on these tangential, but important, 
research, and treatment tools?
    Answer. CDC collects and maintains individual level data on the 
diagnosis and treatment of childhood cancer cases in 45 States and the 
District of Columbia. The National Cancer Institute (NCI) collects 
similar data in the remaining 5 States and these data are combined to 
describe the incidence of cancer in the United States. Each year data 
are collected on approximately 12,000 to 13,000 cancer cases among 
children younger than 20 years of age. Data are collected on 
demographics, place of residence, type of cancer and stage at 
diagnosis, as well as first course of treatment. To fully understand 
the requirements for and feasibility of conducting national rapid case 
ascertainment for childhood cancers, CDC will host a meeting in the 
fall of 2009 which will include experts in childhood cancer research 
and cancer surveillance as well as critical partners such as the NCI 
and the American Cancer Society. One of the goals of this meeting will 
be to lay out all possible approaches that could be taken to address 
the data needs for childhood cancer research. In addition, optimal 
designs of a rapid-case ascertainment system will be described and 
explored for future planning.
    CDC supports and encourages research utilizing cancer registry 
data. For example, CDC provides data annually to the Central Brain 
Tumor Registry of the United States which conducts research and 
provides detailed data on benign and malignant brain tumors among 
children. In addition, CDC utilizes cancer registry data to report 
incidence and geographic variation of childhood cancer. CDC encourages 
and provides leadership in the use of State and national data for 
research into treatment and survival among children diagnosed with 
cancer and will establish collaborative relationships with the 
pediatric cancer community that are needed to promote this research. 
Working with State central cancer registries, CDC promotes the use of 
registry data for research purposes within the States and the District 
of Columbia. CDC is active in developing electronic reporting systems 
for cancer surveillance data which holds great promise in improving the 
timeliness of data.
                                 ______
                                 
              Questions Submitted by Senator Thad Cochran
    Question. In your May 6 testimony on Health Reform in the 21st 
Century before the House Committee on Ways and Means, you noted the 
need for investments in prevention and wellness. In allocating those 
investments, will you devote any additional resources to the prevention 
of osteoporosis, a disease that 10 million Americans have and 34 
million are at risk for, and that costs our healthcare system an 
estimated $19 billion per year?
    Answer. The Recovery Act included $1 billion for prevention and 
wellness programs including $650 million for a prevention and wellness 
initiative. Details regarding this initiative will be announced this 
summer. Our health reform efforts will build on this initial investment 
in health reform by supporting proposals that improve access to 
appropriate clinical prevention services such as osteoporosis screening 
in postmenopausal women and community-based prevention interventions 
that target the main causes of chronic disease.
    Question. In addition to a renewed focus on prevention, many of the 
health reform proposals under consideration include programs for 
chronic disease management. Given that 10 million Americans have 
osteoporosis and another 2 million Americans suffer from other rare 
diseases of the bone like Paget's disease of the bone and osteogenesis 
imperfecta, will you include these bone diseases as part of such 
disease management programs?
    Answer. Yes. Osteoporosis is a classic example of a disease 
susceptible to chronic disease management. Models of chronic disease 
management apply to any disease that requires ongoing medical 
management and monitoring and will not be applied on a restrictive 
basis only to named diseases. This is why we feel it is important to 
avoid listing specific diseases for coverage--it implies that anything 
not listed is excluded. We take an entirely inclusive approach. The 
goal is to improve people's health.
                                 ______
                                 
               Questions Submitted by Senator Judd Gregg
                      refugee resettlement program
    Question. As you know, the main objective of the refugee 
resettlement program is to assist refugees so they become self-
sufficient in the shortest period of time. Unfortunately, the economic 
crisis has made it more difficult for refugees to achieve this goal, 
making programs that provide employment services all the more critical, 
especially the Voluntary Agency Matching Grant program, which enables 
refugees and other eligible persons to become self-sufficient within 4 
to 6 months from the date of arrival in the United States without 
resorting to Federal and State welfare programs. Leveraging public 
funds with private donations at a 2:1 ratio, the program currently 
serves approximately 27,000 individuals and is arguably the most 
successful job placement program for refugees with 80 percent of fiscal 
year 2008 participants achieving self-sufficiency. Given the overall 
objective of the refugee resettlement program, do you believe enough 
resources are being allocated to the Voluntary Agency Matching Grant 
program to maximize utility?
    Answer. The current economic conditions have made it more difficult 
for refugees to gain employment quickly, even for those in the Matching 
Grant program, which historically has been the most successful method 
for placing refugees into employment quickly. As a result, refugees and 
other eligible populations are accessing cash and medical assistance 
for longer periods of time, often for the full 8 months for which they 
are currently eligible. The number of refugees also is on the rise, 
and, for the first time since 2001, the number of arrivals appears to 
be approaching the refugee ceiling set by the State Department. Office 
of Refugee Resettlement will closely monitor arrivals and benefit 
access, and provide updated cost estimates to Congress as necessary, 
including resources provided to the Matching Grant program.
    Question. Recently, the administration requested additional funds 
to support efforts to combat H1N1 influenza, including the authority to 
use Project BioShield Special Reserve Funds (SRF) to fund the 
development and/or procurement of an H1N1 influenza vaccine. As you 
know, Congress created the Project Bioshield SRF to procure medical 
countermeasures against chemical, biological, radiological, and nuclear 
(CBRN) threats and appropriated $5.6 billion to remain available until 
2013. A transfer of funds from the Project Bioshield SRF could have a 
devastating impact on efforts to develop countermeasures for CBRN 
threats and call into question the Government's commitment to procure 
such products, which could force companies to scale back, or abandon, 
efforts to produce biosecurity products. Recognizing the importance of 
pandemic influenza preparedness, how does the Department intend to 
balance these two critical priorities in the near-term? What do you 
believe is the appropriate funding level for the SRF to adequately 
support near-term CBRN acquisitions and provide confidence to the 
biodefense industry?
    Answer. The Biomedical Advanced Research and Development Authority 
(BARDA) within the Department of Health and Human Services (HHS) Office 
of the Assistant Secretary for Preparedness and Response develops and 
procures medical countermeasures for CBRN threats, pandemic influenza, 
and emerging infectious diseases. BARDA programs are funded through the 
SRF (CBRN countermeasure procurement), pandemic influenza funding 
(including for advanced development and procurement), and annual 
appropriations for advanced research and development (CBRN 
countermeasures). HHS' intent is to continue to utilize the SRF and 
annual advanced development appropriations for their intended uses 
(i.e., the procurement and development of CBRN countermeasures, 
respectively).
    Project BioShield was funded through the Department of Homeland 
Security (DHS) Appropriations Act of 2004 (Public Law 108-90) which 
established the SRF by advance-appropriating $5.6 billion for the 
procurement of countermeasures against CBRN agents from fiscal year 
2004 to fiscal year 2013. The act allows the HHS Secretary, with 
concurrence from the DHS Secretary and approval from the Director of 
OMB, to develop and procure products that are within 8 years of FDA 
approval. DHS has issued Material Threat Determinations and Population 
Threat Assessments for 13 CBRN agents, upon which the BARDA 
Implementation Plan is based. To date BARDA has obligated $2 billion of 
the Special Reserve Fund on 5 CBRN programs that have delivered anthrax 
vaccines and therapeutics, botulinum antitoxins, and radiological drugs 
to the Strategic National Stockpile. In fiscal year 2009, Congress 
transferred $412 million from the SRF to support CBRN advanced 
development and pandemic influenza. The fiscal year 2010 President's 
budget proposes transferring $305 million from the SRF for CBRN 
Advanced Development. The long-term success of Project BioShield is 
directly tied to the success of the Advanced Development program. Over 
the next 4 years, BARDA will obligate the remaining $2.9 billion in the 
SRF by expanding its portfolio of late-stage products in anthrax 
vaccines, smallpox antivirals, chemical agent antidotes, and other 
radiological drugs in order to develop next-generation products.
                                 ______
                                 
           Question Submitted by Senator Kay Bailey Hutchison
                        medical countermeasures
    Question. In addition to the recently circulating H1N1 and H5N1 
influenza strains, there is a host of emerging infectious diseases and 
biothreat agents for which we need to develop medical countermeasures 
in order to protect the health of the American people. In light of the 
broad range of possible biothreats, as well as the long lag time and 
high costs associated with developing drugs, how does HHS plan to 
transition R&D into these lifesaving countermeasures in quantities 
large enough to cover our population? And how does HHS plan to 
disseminate them rapidly enough to be able to make a difference in the 
event of an outbreak or attack?
    Answer. HHS has implemented the Public Health Emergency Medical 
Countermeasures Enterprise (PHEMCE) to manage the development and 
deployment of CBRN countermeasures, from the basic research phase at 
NIH to procurement through Project BioShield. The PHEMCE is a 
coordinated, inter-agency effort led by the HHS Assistant Secretary for 
Preparedness and Response and includes the Centers for Disease Control 
and Prevention, Food and Drug Administration, and the National 
Institutes of Health (NIH). Ex officio members include the Department 
of Homeland Security, Department of Veterans Affairs, and the 
Department of Defense. The PHEMCE defines and prioritizes CBRN medical 
countermeasure (MCM) requirements, integrates and coordinates research, 
development, procurement, and deployment and use strategies for MCMs. 
The investment in biodefense research and development has led to 
fundamental discoveries and has laid the foundation for promising drugs 
and vaccines for biodefense purposes. To date, two programs started at 
NIH have reached the level of maturity required for consideration into 
a late-stage development program funded under Project BioShield (i.e., 
product is within 8 years of FDA approval). Once products are procured 
through Project BioShield, they are placed in the Strategic National 
Stockpile (SNS). The SNS works with State and local partners to ensure 
that medical countermeasures can be distributed as quickly as possible 
during a public health emergency.

                         CONCLUSION OF HEARINGS

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