[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]



 
 LEGISLATIVE HEARING ON MISCELLANEOUS PUBLIC HEALTH LEGISLATION, H.R. 
1852, CHILDREN'S HOSPITAL GME SUPPORT REAUTHORIZATION ACT OF 2011, AND 
        H.R. 2005, COMBATING AUTISM REAUTHORIZATION ACT OF 2011

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 11, 2011

                               __________

                           Serial No. 112-72


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


      Printed for the use of the Committee on Energy and Commerce

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                              __________


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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    HENRY A. WAXMAN, California
  Chairman Emeritus                    Ranking Member
CLIFF STEARNS, Florida               JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky                 Chairman Emeritus
JOHN SHIMKUS, Illinois               EDWARD J. MARKEY, Massachusetts
JOSEPH R. PITTS, Pennsylvania        EDOLPHUS TOWNS, New York
MARY BONO MACK, California           FRANK PALLONE, Jr., New Jersey
GREG WALDEN, Oregon                  BOBBY L. RUSH, Illinois
LEE TERRY, Nebraska                  ANNA G. ESHOO, California
MIKE ROGERS, Michigan                ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina   GENE GREEN, Texas
  Vice Chairman                      DIANA DeGETTE, Colorado
JOHN SULLIVAN, Oklahoma              LOIS CAPPS, California
TIM MURPHY, Pennsylvania             MICHAEL F. DOYLE, Pennsylvania
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          CHARLES A. GONZALEZ, Texas
BRIAN P. BILBRAY, California         JAY INSLEE, Washington
CHARLES F. BASS, New Hampshire       TAMMY BALDWIN, Wisconsin
PHIL GINGREY, Georgia                MIKE ROSS, Arkansas
STEVE SCALISE, Louisiana             JIM MATHESON, Utah
ROBERT E. LATTA, Ohio                G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington   JOHN BARROW, Georgia
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            DONNA M. CHRISTENSEN, Virgin 
BILL CASSIDY, Louisiana              Islands
BRETT GUTHRIE, Kentucky              KATHY CASTOR, Florida
PETE OLSON, Texas
DAVID B. McKINLEY, West Virginia
CORY GARDNER, Colorado
MIKE POMPEO, Kansas
ADAM KINZINGER, Illinois
H. MORGAN GRIFFITH, Virginia

                                 7_____

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois               EDOLPHUS TOWNS, New York
MIKE ROGERS, Michigan                ELIOT L. ENGEL, New York
SUE WILKINS MYRICK, North Carolina   LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          CHARLES A. GONZALEZ, Texas
PHIL GINGREY, Georgia                TAMMY BALDWIN, Wisconsin
ROBERT E. LATTA, Ohio                MIKE ROSS, Arkansas
CATHY McMORRIS RODGERS, Washington   JIM MATHESON, Utah
LEONARD LANCE, New Jersey            HENRY A. WAXMAN, California (ex 
BILL CASSIDY, Louisiana                  officio)
BRETT GUTHRIE, Kentucky
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)

                                  (ii)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     3
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, opening statement....................................     5
Prepared statement...............................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................    17
Hon. Leonard Lance, a Representative in Congress from the State 
  of New Jersey, prepared statement..............................    59
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, prepared statement..............................    61
Hon. James D. Dingell, a Representative in Congress from the 
  State of Michigan, prepared statement..........................    63

                               Witnesses

Janet Heinrich, Associate Administrator, Bureau of Health 
  Professions, Health Resources and Services Administration, 
  Department of Health and Human Services........................    18
    Prepared statement...........................................    20
Thomas Insel, Director, National Institute of Mental Health, 
  National Institutes of Health..................................    25
    Prepared statement...........................................    28
    Answers to submitted questions...............................    65

                           Submitted Material

Letters, dated May 19, 2011, from Jim Mandell, Board Chair, and 
  Lawrence A. McAndrews, President and CEO, National Association 
  of Children's Hospitals to Mr. Pitts and Mr. Pallone (submitted 
  by Mr. Pallone)................................................     9
Letter, dated May 26, 2011, from Benard Dreyer, President, 
  Academic Pediatric Association, et al. to subcommittee 
  leadership (submitted by Mr. Pallone)..........................    11
Letter, dated May 24, 2011, from Atul Grover, Chief Advocacy 
  Officer, Association of American Medical Colleges, to 
  subcommitte leadership et al. (submitted by Mr. Pallone).......    13
Letters, dated July 8, 2011, from Rick Pollack, Executive Vice 
  President, American Hospital Association, to Mr. Pitts and Mr. 
  Pallone (submitted by Mr. Pallone).............................    14
Letter, dated July 11, 2011, from James L. Madara, Executive Vice 
  President and CEO, American Medical Association, to 
  subcommittee leadership (submitted by Mr. Pallone).............    16


 LEGISLATIVE HEARING ON MISCELLANEOUS PUBLIC HEALTH LEGISLATION, H.R. 
1852, CHILDREN'S HOSPITAL GME SUPPORT REAUTHORIZATION ACT OF 2011, AND 
        H.R. 2005, COMBATING AUTISM REAUTHORIZATION ACT OF 2011

                              ----------                              


                         MONDAY, JULY 11, 2011

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 2 p.m., in room 
2123, Rayburn House Office Building, Hon. Joseph R. Pitts 
(chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Burgess, Blackburn, 
Gingrey, Latta, Cassidy, Guthrie, Upton (ex officio), Pallone, 
Dingell, and Waxman (ex officio).
    Also present: Representative Christensen.
    Staff present: Jim Barnette, General Counsel; Brenda 
Destro, Professional Staff Member, Health; Andy Duberstein, 
Special Assistant to Chairman Upton; Debbee Keller, Press 
Secretary; Ryan Long, Chief Counsel, Health; Katie Novaria, 
Legislative Clerk; Heidi Stirrup, Health Policy Coordinator; 
Stephen Cha, Minority Senior Professional Staff Member; Alli 
Corr, Minority Policy Analyst; and Ruth Katz, Minority Chief 
Public Health Counsel.
    Mr. Pitts. The subcommittee will come to order. The chair 
recognizes himself for 5 minutes for an opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Today's legislative hearing will focus on two bills: H.R. 
1852, the Children's Hospital Graduate Medical Education 
Reauthorization Act of 2011, the bill that I introduced with 
Ranking Member Pallone; and H.R. 2005, the Combating Autism 
Reauthorization Act of 2011, introduced by Congressman Chris 
Smith. I will focus my remarks on the CHGME reauthorization.
    In his fiscal year 2012 budget President Obama proposed 
eliminating the Children's Hospital Graduate Medical Education 
program, a program that provides more than $300 million a year 
to 56 freestanding children's hospitals across the U.S. Three 
of these hospitals are located in my home State of 
Pennsylvania: the Children's Hospital of Philadelphia, the 
Children's Hospital of Pittsburgh, and Saint Christopher's 
Hospital for Children. Due to its proximity many of my 
constituents travel to the Children's Hospital in Philadelphia 
to seek treatment for their children.
    The CHGME program trains 40 percent of our Nation's 
pediatricians and 43 percent of pediatric subspecialists. More 
than 5,000 residents take part in this program every year. The 
1990s saw a 13 percent decline in the number of pediatric 
residents. However, since 1999 when the CHGME program was 
enacted, the number of pediatric residents has increased 35 
percent. During the program's lifetime, $2 billion has gone to 
train the next generation of pediatricians and pediatric 
subspecialists.
    The program's current authorization expires September 30, 
2011, and that is why I and Ranking Member Pallone introduced 
H.R. 1852, to reauthorize the program at the current level of 
$330 million over the next 5 years. This is a fiscally 
responsible bill which continues the CHGME program at its 
current authorization. We cannot simply zero out this important 
program, as the administration has requested, and hope that 
other Federal programs not specifically dedicated to pediatric 
health care will pick up the slack.
    To date this bill has garnered over 90 cosponsors, 
including more than half of the members of this subcommittee. 
This is not a partisan issue; it is about children's health and 
lives. I urge my colleagues to support this bill.
    I also support Representative Chris Smith's Combating 
Autism Reauthorization Act, H.R. 2005.
    I will now yield to the chairman of the committee, Mr. 
Upton, for the remainder of my time.
    [The prepared statement of Mr. Pitts follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
   OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Upton. Well, thank you. And certainly this legislative 
hearing gives this subcommittee an opportunity not only to 
review the progress of these two important bills, but also to 
demonstrate our ability to work in a bipartisan manner. And 
with the passage of CHGME in 1999, freestanding children's 
hospitals began receiving funds to support the pediatric 
medical residency programs. And as a result, the number of 
pediatricians in the U.S. has steadily grown.
    Over 40 percent of pediatricians and pediatric specialists 
are trained in the 56 freestanding children's hospitals that 
receive funding. The program has enjoyed bipartisan support. It 
makes the Obama administration's decision to eliminate funding 
for this in their 2012 budget very troubling. Even Secretary 
Sebelius expressed regret about the decision to zero out 
funding while testifying before the Energy and Commerce 
Committee earlier.
    We look forward to the testimony today and its impact on 
funding for pediatric medical residency programs in the future 
of the program.
    I would also say that the Combating Autism Act of 2006 
consolidated and intensified the Federal effort to understand 
and treat autism spectrum disorders. It also addressed the need 
to monitor the disorder and bring relief to the children and 
families who live with the challenge of autism. This year the 
Interagency Autism Coordinating Committee released its 
strategic plan for autism spectrum disorders research that 
provides a blueprint for researchers and a basis for 
partnerships for the public and private sector.
    Recent results from research on early screening genetics 
and prenatal conditions are hopeful signs that the Federal 
effort is working. The interagency coordinating committee is 
something that I am particularly interested in. I want to hear 
from the witnesses on how this committee has worked and whether 
the improved coordination of the Department's activities is 
something that should be emulated elsewhere.
    Too often I have visits from patient groups telling a story 
about how a particular agency's activities did not complement 
another's work. HHS is a unified Department and its differing 
agencies should have the same strategic vision that is 
coordinated to achieve maximum results.
    I look forward to the testimony and look forward to working 
with Republicans and Democrats on this very, very important 
issue, and I yield back.
    [The prepared statement of Mr. Upton follows:]
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. The chair thanks the gentleman, and now 
recognizes the ranking member of the subcommittee, Mr. Pallone, 
for a 5-minute opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you Chairman Pitts. I want to thank you 
for holding this hearing on two very important public health 
bills, and I welcome the bipartisan spirit that brings us 
together today.
    Specifically, I am proud of the bill that you and I 
introduced together, H.R. 1852, the Children's Hospital 
Graduate Medical Education Support Reauthorization Act of 2011. 
The Children's Hospital Graduate Medical Education program is a 
true success story. As every parent knows, it is so important 
to have a trusted doctor to turn to when your child gets sick. 
Since 1999 the Children's Hospital Graduate Medical Education 
program has helped to make sure that the doctor is there and 
prepared to diagnose any symptoms our children face.
    Today we are still experiencing a shortage of pediatric and 
specialty physicians in New Jersey and across the country. So 
you can imagine how disappointed I was to see that the 
President suspended funding for the GME program in this year's 
budget.
    In 2009 the program supported the training of 5,361 
resident positions nationally. When it was first created in the 
1990s the program single-handedly reversed the declines in 
pediatric training programs which threatened the stability of 
the pediatric workforce. Continuing its critical program, it is 
certain to have the same major impact on promoting access to 
primary care and an access to specialty care for children.
    The small class of hospitals that receive this funding, 
which includes the Children's Specialized Hospital in my 
district in New Brunswick represents about 1 percent of 
hospitals nationwide but trains approximately 40 percent of all 
pediatricians. In addition, the funding allows all 56 hospitals 
in 30 States who participate to enhance hospitals' research 
capabilities and improve hospitals' ability to provide care to 
vulnerable and underserved children.
    Chairman Pitts, together, along with nearly 100 of our 
colleagues who are cosponsors, we recognize that this 
legislation will help keep doctors in the pipeline who are 
prepared to address the special health care needs of our 
Nation's children.
    Now, today we are also considering the Combating Autism 
Reauthorization Act of 2011. Autism spectrum disorder affects 
so many children in the United States, including my State of 
New Jersey. In fact, CDC has estimated that one in 110 children 
are classified as having an autism spectrum disorder. In New 
Jersey that number is more prevalent, affecting one in every 94 
children, the highest prevalence in the Nation. Despite the 
high numbers of cases and the growing focus on this disease, 
there are still many providers who are unaware of the best 
methods to diagnose and treat the disorder, and that is why 
autism awareness is so important.
    We must treat autism as a condition of urgent public health 
concern and raise awareness in education of the disorder. As 
such, Congress recognized this public health crisis. In 2000 we 
passed the Children's Health Act that included specific 
activities related to autism, such as research at NIH, other 
developmental disability surveillance and research, and 
information in education. Those programs have continued to be 
reauthorized, the last time in 2006, with the acknowledgement 
that unfortunately the prevalence of autism continues to grow.
    And that is why I support H.R. 2005 which reauthorizes 
these programs until 2014. This critical bill will help 
educate, promote research, promote early screening and advanced 
early diagnosis of autism spectrum disorders and other 
developmental disabilities.
    I just wanted to say I know we had a very short weekend, we 
were only home, I guess, Saturday and Sunday, but interestingly 
enough, without my constituents knowing that either of these 
bills were on the agenda today, I actually had people--you 
know, just regular constituents--who came up to me at various 
events and mentioned what I was going to do about both of these 
areas. And I said, well, in fact we are having a hearing 
Monday. We are going to address both of these problems. So 
thank you, Chairman Pitts, and thank you again for the 
bipartisan nature of this.
    Mr. Pitts. Thank you.
    Mr. Pallone. Mr. Chairman, could I ask that these letters 
be admitted to the record--or I ask unanimous consent. I think 
you have them all. It is the National Association of Children's 
Hospitals, American Academy of Pediatrics, Association of 
American Medical Colleges, American Hospital Association and 
American Medical Association.
    Mr. Pitts. Without objection, so ordered.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pallone. Thank you.
    Mr. Pitts. Thank you, Mr. Pallone. And at this time I yield 
5 minutes to the vice chairman of the subcommittee, Dr. 
Burgess, for his opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. I thank the chairman for yielding. I thank you 
for holding the hearing on these two important 
reauthorizations.
    Let me focus my time on H.R. 1852, the Children's Hospital 
Graduate Medical Education Support Reauthorization Act of 2011. 
I am grateful to have had the chance to help author and serve 
as a cosponsor of the Children's Hospital GME Support 
Reauthorization Act of 2011 with Chairman Pitts, Ranking Member 
Pallone, and Mrs. Capps.
    In the decade since the program was first fully funded, it 
has proved to be a significant success. Graduate medical 
education levels the playing fields between adult and 
children's hospitals in regards to the training programs and 
provides a dedicated source of funding to train future doctors 
in cutting-edge pediatrics. According to the American Academy 
for Pediatrics, for most subspecialties there are, on average, 
100,000 and 200,000 children per provider across hospital 
regions. There are only about 28,000 pediatric medical 
subspecialists and surgical specialists to care for over 80 
million children in the United States.
    Prior to the Children's Hospital GME enactment, the number 
of residents in Children's Hospitals' residence programs had 
declined by over 13 percent, but the passage of this bill has 
enabled, and the appropriate funding has enabled the Children's 
Hospitals to reverse this decline and increase their training 
by 35 percent.
    Texas has an even greater need of more pediatricians and 
pediatric subspecialists. Texas currently has 60 pediatricians 
per 100,000 children, well below the national average of just 
under 90. But Children's Graduate Medical Education has helped 
close that gap through Texas Children's Hospitals. For example, 
Children's Medical Center Dallas is one example of a premier 
hospital whose mission has been greatly enhanced by the 
Children's Hospital Graduate Medical Education and has found 
that over 68 percent of the residents they train go on to 
practice within a 100-mile radius of the training facility.
    Of course I am reminded that just a few years ago, probably 
8 years ago in 2003, Children's Hospital in Dallas had that 
stunning success where they separated the two little Egyptian 
twins who had been born conjoined. And I saw a special on NPR a 
few nights ago about how their progress has continued now that 
they are back in their native country. But what an incredible 
day that was through that lengthy operation. It required the 
building of a special operating table, it involved all 
departments within the hospital. They all came together and 
worked diligently to save these two little boys. And it was an 
incredible story that was told in 2003 and still chokes you up 
when you see it many years later. But Children's adds a 
priceless asset to the region, and access to specialists and 
subspecialists across the north Texas area.
    So I am grateful that our witnesses are here with us today. 
I am looking forward to hearing their testimony and how these 
programs are administered and how these reauthorizations will 
continue the great work that has already commenced.
    Mr. Chairman, I would be happy to yield the balance of my 
time to anyone on our side who would seek recognition. If not, 
I will yield back.
    Mr. Pitts. The chair thanks the gentleman.
    We will proceed with the testimony at this time. I thank 
the witnesses for agreeing to appear before the committee. The 
first witness is Dr. Janet Heinrich. She is the Associate 
Administrator of the Bureau of Health Professions at the Health 
Resources and Services Administration. This is the entity that 
oversees the Children's Hospital Graduate Medical Education 
program.
    Our second witness is Dr. Thomas Insel, the Director of the 
National Institute of Mental Health at the National Institutes 
of Health and the chair of the Interagency Autism Coordinating 
Committee.
    Your written testimony will be made part of the official 
record. We ask that you summarize your opening statement in 5 
minutes.

 STATEMENTS OF JANET HEINRICH, ASSOCIATE ADMINISTRATOR, BUREAU 
     OF HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES 
 ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND 
 THOMAS INSEL, DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH, 
                 NATIONAL INSTITUTES OF HEALTH

    Mr. Pitts. Dr. Heinrich, you may begin your prepared 
testimony.

                  STATEMENT OF JANET HEINRICH

    Ms. Heinrich. Chairman Pitts, Ranking Member Pallone and 
members of the subcommittee, thank you for the opportunity to 
testify today on H.R. 1852, the Children's Hospital GME Support 
Reauthorization Act of 2011. I am Jan Heinrich, Associate 
Administrator of the Bureau of Health Professions at the Health 
Resources and Services Administration. We appreciate your 
interest in our work and welcome the opportunity to discuss the 
Children's Hospital GME program with you.
    First I would like to give you an overview of HRSA and give 
you an idea of our vision and mission. HRSA helps the most 
vulnerable Americans receive quality primary health care 
without regard to their ability to pay. The agency works to 
expand access to health care for millions of Americans--the 
uninsured, the underinsured and the vulnerable. HRSA recognizes 
that people need to have access to primary care, and through 
its programs and activities the agency seeks to meet these 
needs.
    In addition to helping the most vulnerable Americans 
receive quality care, we also serve as a source of support for 
the Nation's health profession's education and training 
infrastructure through our work with medical schools, nursing 
schools, residency training programs and community-based 
training organizations. Our programs fund the full spectrum of 
training programs, from pipeline programs aimed at youth, 
hoping to interest them in health professions; to support for 
students and residents in health professions training; to 
ongoing investments in the continuing education needed to 
maintain the workforce skills in a changing health care 
environment.
    We also support the infrastructure for quality health 
professions training, including faculty development, 
innovations in training, curriculum changes and the development 
of community-based clinical training sites to expose students 
to the diverse needs of our communities. HRSA programs 
demonstrate our commitment to ensuring that the Nation has the 
right practitioners with the right skills working where they 
are needed most.
    The focus of today's hearing is the children's GME payment 
program, and I would like to provide an overview for you. The 
CHGME Payment Program is authorized by section 340(e) of the 
Public Health Service Act through fiscal year 2011, as was 
stated, and is administered by the Bureau of Health 
Professions. The program provides Federal funding to the 
Nation's Children's Hospital to help them maintain the Graduate 
Medical Education programs that train resident physicians.
    Since its implementation in 2000, CHGME has provided more 
than $2.5 billion to children's hospitals to support residency 
training for general pediatrics, pediatric medical and surgical 
subspecialists, as well as pediatric experiences for adult 
medical and surgical specialists in other fields, as well as 
dentists. The CHGME funding is determined by annual 
appropriations. The size of the appropriation, the number of 
participating hospitals and the number of residents trained 
each year impact the amount of resources each participating 
children's hospital will receive from the program. Funds are 
distributed among eligible institutions based on statutory 
formulas that reflect direct and indirect Graduate Medical 
Education expenses. Payments are made to participating 
children's hospitals on a monthly basis. Much of what we know 
about the Children's Hospital Payment Program comes from annual 
reports to HRSA that participating children's hospitals are 
required by current law to submit.
    Let me give you some basic statistics. In fiscal year 2010 
the program supported 56 children's hospitals located in 29 
States and Puerto Rico which were responsible for the training 
of about 5,800 FTE residents. To determine the CHGME support, a 
participating Children's Hospital may include in its 
calculation of full-time equivalent residents both its full-
time residents and the portion of time associated with 
residents who rotate through the hospital.
    In fiscal year 2010 the average award through the program 
was $5.4 million. It is important, though, to help you 
understand that there is a wide range in the amounts that each 
hospital receives. That range is between $21,000 to about $22 
million in a couple of facilities. This variation, again in 
dollars, is due to the variation in the size of the residency 
training program and the number of residents. The estimated 
overall average award per resident FTE is about $71,000. In 
fiscal year 2011, $268 million was appropriated for the CHGME 
program.
    And, Mr. Chairman, I am happy to answer any questions.
    Mr. Pitts. Thank you Dr. Heinrich.
    [The prepared statement of Ms. Heinrich follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. Dr. Insel, you are recognized for 5 minutes for 
your opening statement.

                   STATEMENT OF THOMAS INSEL

    Mr. Insel. Thank you. Good afternoon, Chairman Pitts and 
Ranking Member Pallone, members of the committee. I am Tom 
Insel. I am the Director of the National Institute of Mental 
Health at the NIH, and I have served as the Chair of the 
Interagency Autism Coordinating Committee, which I will call 
the IACC, which was originally created by the Children's Health 
Act of 2000 and then reestablished by the Combating Autism Act 
of 2006. I have been Chair since my arrival at NIH in 2002, so 
I have been doing this for quite a few years.
    First I would like to express my appreciation for the 
opportunity to give you some background on how the existing act 
has facilitated unprecedented collaboration between Federal 
agencies and private organizations, enabling what I think is 
really amazing progress in the field of autism research and 
serving to sharpen our focus as well on the need for better 
services for people with autism and for their families.
    At NIH we are very grateful for the strong support that you 
in Congress have always shown for us and the thousands of 
researchers around the country that we support. And as Chair of 
the IACC, I also would like to express the gratitude of all the 
Federal agencies--and there are many that are members of the 
committee--for your continued interests and encouragement.
    The Combating Autism Act, which I will call the CAA, had 
five general provisions: centers of excellence; surveillance; 
education for early detection and intervention; the IACC, that 
is, this coordinating committee; and then a section on 
authorization for funding.
    The 11 autism centers of excellence, the surveillance 
efforts at the CDC, the programs for early detection and 
intervention and funding for all of these programs is 
authorized to continue with or without reauthorization of the 
Combating Autism Act. The one provision that requires 
reauthorization to continue is this IACC, this coordinating 
committee. And that is scheduled to sunset on September 30, 
2011. That is basically precisely what it says within the act.
    For this reason let me just focus for a few moments on this 
coordinating committee and what it has accomplished. I will be 
happy to take questions from you later about other provisions 
if you have interest in any of them.
    A word about autism for those of you who aren't close to 
this area, although I appreciate the comments from Mr. Pallone 
that most people are hearing more about autism than they might 
have ever imagined. Autism is now called autism spectrum 
disorder, meaning that it is a diverse collection of disorders 
that share in common impairments in verbal and nonverbal 
communication skills and social interactions, as well as, 
restricted, repetitive and sometimes stereotype patterns of 
behavior.
    By definition the disorder starts by age three. The degree 
and specific combination of impairments can vary from one 
individual to the next, creating a heterogeneous disorder that 
can range in impact from actually quite mild to severely and 
significantly disabling.
    Two decades ago, Dr. Burgess, when you were in medical 
school and I was in medical school, we probably didn't hear 
much about it, but at this point we are amazed by how frequent 
we are seeing autism in clinics, particularly in pediatric 
clinics, in neuropsychiatric clinics, where the CDC's latest 
prevalence estimates are 1 in 110 children, that is 1 in 70 
boys, that is amongst the 8-year-old cohort today being 
diagnosed with autism spectrum disorder. And it is therefore 
that the disorder has become an urgent national health 
priority.
    In 2006 Congress passed the Combating Autism Act to 
strengthen Federal coordination around this issue and to 
enhance public-private collaborations in order to accelerate 
research to improve the lives of people with ASD and their 
families.
    The CAA, the act itself, outlines the membership of this 
committee. This IACC includes both representatives of Federal 
agencies and public members representing a diverse set of 
stakeholder groups within the community. Currently the IACC 
includes two people with autism spectrum disorder, several 
parents of children and adults with ASD, members of advocacy 
research and service provider communities, and officials from 
several Federal agencies.
    There are actually six parts of the Department of Health 
and Human Services: Department of Education, and, in addition 
to that, five NIH institute directors, as well as Francis 
Collins, the Director of the NIH, who also serves on this 
committee. You can imagine the challenge of trying to chair 
such a committee, but it has actually been quite inspiring to 
have this group of people around the table.
    The major autism research and service organizations 
represented on this committee include Autism Science 
Foundation, Autistic Self-Advocacy Network, Autism Speaks, Safe 
Minds, the Simons Foundation, the Southwest Autism Research and 
Resource Center, and the UC Davis MIND Institute. So it is a 
very diverse, very experienced, and I think very committed 
group.
    In addition to the voices and perspectives added by the 
members of the IACC, the committee has fostered public 
participation by having public comment periods at every full 
meeting, regularly inviting written public comments, conducting 
formal requests for information from the public and holding 
town hall meetings. And it has provided a high level of 
transparency for the public by actively disseminating 
information about the IACC activities via email, the IACC Web 
site, Webcasts and even Twitter. By including both Federal and 
public members on the committee and by fostering public 
engagement through a variety of means, the IACC ensures that a 
diversity of ideas and perspectives on ASD are brought to the 
table to inform the activities and recommendations of the 
committee. This is a committed group, by all measures; while 
the law only requires the committee to meet twice a year, since 
2007 the committee has met around 16 times per year, including 
full committee and subcommittee meetings, workshops and town 
hall meetings, the most recent of which was a subcommittee 
meeting this morning at 8:00 a.m. So this is a very, very 
active group.
    I think given the time and the number of questions I hope 
you will have, I am not going to go into a great deal of detail 
about some of the research and some of the efforts that this 
committee has accomplished. There is actually quite a bit we 
could talk about. All of this is in the written testimony, and 
I would just steer you towards that.
    Let me say that looking back over the past 5 years since 
the passage of the act, I think that this committee has really 
served to focus efforts across the Federal Government, bringing 
these Federal agency representatives for research services and 
education, bringing parents, people with ASD, scientists, 
clinicians and others together to work as a team to address the 
issues that face everyone, and bringing a wide variety of 
expertise to what is really a difficult and, I must say, 
evolving area. In doing so it has produced a strategic plan to 
guide and focus Federal research efforts and to catalyze 
public-private partnerships.
    And hopefully at this time we can talk a bit about what 
some of those are, while also providing a forum for public 
discussion and identification of additional needs from the 
community. And those needs continue to emerge and have been 
something that the committee has continued to adapt to. I think 
we have seen some remarkable progress in the identification of 
how common ASD is within communities, how ASD develops, how we 
can detect it at increasingly earlier ages, and what types of 
interventions, most importantly, the interventions that are 
most effective, especially in very young children.
    The research is moving rapidly towards translation into 
practical tools that can be used in the clinic and community 
settings to change outcomes for people with ASD. In this time 
span, Federal agencies have coordinated efforts to enhance 
critical service programs, identify best practices to support 
the education, health, and employment needs of people on the 
spectrum, and to develop new mechanisms and strategies to 
enable broad access to health care services and supports, all 
leading towards improvement in the quality of life for people 
with ASD.
    Mr. Pitts. All right. If you can wrap up.
    Mr. Insel. I will. The CAA established the IACC to provide 
advice to the Secretary of HHS regarding matters related to ASD 
to create a forum where the public could be actively involved 
in the process and to develop a strategy to guide national 
research efforts. While there has been unequivocal progress, 
much work remains to be done. The reauthorization will be 
critical for continuing this momentum and the stability over 
the IACC over the next 3 years.
    I look forward to your questions. Thank you.
    Mr. Pitts. OK. Thank you, Doctor.
    [The prepared statement of Mr. Insel follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Pitts. I will begin the questioning now, and I 
recognize myself for 5 minutes for that purpose.
    The Interagency Autism Coordinating Committee has been 
praised because it has brought together various HHS agencies 
that work with autism. Can you explain how the agencies 
interacted before the creation of the IACC?
    Mr. Insel. Well, I actually wasn't around prior to that 
time. And I must, say since we have been operational since 2000 
as a committee, it is probably fair to say that prior to 2000 
there was a fairly meager investment from most of the agencies 
in autism. There was certainly less than one-fourth of the NIH 
commitment that we have today. There was activity at the CDC in 
terms of epidemiology, but autism was not seen at that point as 
quite the priority it is today.
    Mr. Pitts. The Combating Autism Act consists of the 
function of the CDC, HRSA, NIH and the Interagency Coordinating 
Committee. If the Combating Autism Act is not reauthorized, 
would NIH, CDC, and HRSA be able to continue its activities 
related to autism?
    Mr. Insel. It will be able to continue its activities 
contingent on appropriations. So I often like to say that 
authorization here is essentially a driver's license. Agencies 
serve as our vehicle. We have got a great road map through the 
strategic plan that the IACC has put together, but at the end 
of the day, whether we have got gas in the car or not depends 
on the appropriators.
    Mr. Pitts. Let me ask a few questions about the strategic 
plan in 2011. What have you learned about risk factors for 
autism spectrum disorders, especially in light of recent news 
of an elevated risk of autism in children whose mothers took 
antidepressants in the year before delivery?
    Mr. Insel. Well, we have got a number of things that are 
emerging through the studies that are longitudinal to look at 
exposures that may increase risks. We also have increasing 
evidence for the importance of genetics as a risk factor. 
Perhaps 15 percent of children with a diagnosis of autism 
spectrum disorder are found today to have a genetic mutation. 
Many of these we didn't know about even 6 months ago. So that 
is an emerging area of risk as well.
    Probably the most important area going forward is 
understanding how these genetic and environmental effects 
interact and to put people at the greatest risk.
    Mr. Pitts. Would you describe, please, the new diagnostic 
tools for early screening and diagnosis of autism spectrum 
disorders?
    Mr. Insel. What is the most exciting on the diagnostic 
front is the possibility that we could begin to detect autism, 
not at age 4-1/2 or 4 and 3 months, but before the second 
birthday. And the way in which that is happening, really it 
happens--the most recent data comes from two fronts. One is 
just a simple 5-minute screening device that is available in 
the pediatrician offices that would be done at 12 months. And 
we are seeing that that picks up about 30 percent of the cases.
    In fact, where this was piloted in San Diego, those 
pediatricians who agreed to do it as part of the pilot have 
continued to take this on, and we now have over 1,000 
pediatricians in San Diego County who are continuing to work 
with this possibility of actually extending that much more 
broadly.
    But I think where we are getting even more traction is from 
the possibility that we could detect autism through sort of a 
biomarker; that is, looking at things like eye scanning, look 
at other very subtle behavioral changes that might not show up 
with a simple checklist coming from parents. Doing that, it 
looks like we have got about 100 percent sensitivity--I am 
sorry, 100 percent specificity, as early as 14 months by using 
a simple video monitor task to detect who will look at faces 
versus who will look at geometric shapes as a preference. And 
we have been able to now show the power of that to detect 
autism very quickly and very early on.
    Mr. Pitts. Are there any significant gaps in the research 
plan that need to be filled?
    Mr. Insel. There certainly are. I think the two places that 
we are seeing the greatest emerging need is watching the 
transition to adulthood. And this was a place that the IACC 
hadn't really been focused in 2008 and 2009. But as time has 
gone on, what we have heard from the public and what we are 
hearing from in meetings that we have in the IACC, is this 
aging cohort. Here, aging means becoming adults, going from 
being children with autism to being young adults, and the fact 
that many of the social supports and the service resources that 
are available to students and to children with autism are no 
longer available as people with autism become adults. It is 
important for us to look at that and to think about both the 
research and service needs at that point.
    The second I would say is, much more broadly, how services 
are provided throughout the country. There is an amazing amount 
of heterogeneity, not only in the needs of people with autism, 
but in the way that those needs are met across various States. 
You and Mr. Pallone happen to come from States that are 
particularly enlightened in their policies for what they do for 
people with autism, but that is not true in all 50 States, and 
the need to think about creating some standards that will be 
helpful as best practices I think is an emerging and actually 
an urgent need for people on the spectrum and for their 
families.
    Mr. Pitts. Thank you. My time is expired. The chair 
recognizes the ranking member for 5 minutes for questioning.
    Mr. Pallone. Thank you, Mr. Chairman. I am trying to get in 
half of Dr. Heinrich and half of Dr. Insel. We will see how I 
do.
    Dr. Heinrich, I wanted to ask about the children's GME. We 
know it is critical to physicians that--you know, to pediatric 
physicians. But I wanted to clarify the difference between this 
program and Medicare GME. Can you briefly explain the obstacles 
for freestanding children's hospitals to access Medicare GME 
for training pediatricians?
    Ms. Heinrich. Sure. The Medicare GME formulas that are used 
to reimburse hospitals really are heavily dependent on the 
services provided to the Medicare population, which usually are 
people 65 and over with various acute chronic conditions. With 
the freestanding children's hospitals, you do not have that 65-
and-over population for the most part, you have children. So it 
disadvantages the Children's Hospital immediately. There also 
is a section of the law that makes it more difficult for 
children's hospitals, actually.
    Mr. Pallone. Can I ask you, are we still seeing a decline 
in the number of pediatricians trained now that we have the 
program?
    Ms. Heinrich. Are we seeing a decline?
    Mr. Pallone. Yes. I mean, I know that at one time before 
the program began there was a decline, but is that still true?
    Ms. Heinrich. To the best our knowledge we are continuing 
to see that residency positions are expanding for pediatricians 
overall. And as we look at numbers of providers, it looks like 
the number of pediatricians are continuing to expand. Whenever 
we talk about the numbers, though, we always have to be worried 
about that retiring population, because just as our overall 
population is aging, so are the health care providers.
    Mr. Pallone. I mean, when I talk to physicians--and I know 
there were some recent reports by your agency for pediatrics--
they usually complain that the subspecialists are what we need 
more; in other words, that we need more people going to certain 
subspecialties. And I know in February 2000, there was a report 
by HRSA that concluded there was a shortage in pediatric 
rheumatologists. And then we expanded the number by 75 percent. 
In December 2008, expert work group on pediatric subspecialty 
capacity HRSA recommended that we expand graduate medical 
education for pediatric subspecialists. Do you agree with the 
findings of these reports in terms of the subspecialists?
    Ms. Heinrich. Congressman Pallone, I am not familiar with 
those particular reports. But anything from 2007 that we have 
published would have been based on even earlier data, so I 
would consider that old data. I prefer actually to see those 
reports and get back to you on whether or not we agree or 
disagree.
    Mr. Pallone. But you agree that the subspecialists in 
general need more support, right? In other words, that that is 
a problem, the subspecialties per se?
    Ms. Heinrich. You know, we have heard as you have from the 
professional associations, that there are shortages in these 
various subspecialties. It is just always very difficult to 
determine the demand for the program.
    Mr. Pallone. I am going to cut you off only because I want 
to go to Dr. Insel, but thank you.
    Let me just ask you these--a couple of these questions. In 
your remarks you mentioned a recent study involving twins which 
found that environmental factors, not just genetic factors, may 
be at play. And these findings are somewhat controversial, as 
you know.
    So I had three questions.
    First, would you explain these findings in more detail? 
Would you give us a brief summary of what the research shows in 
terms of the role of genetics? And to the extent--the third 
one--to the extent environmental factors may be involved, what 
kind of environmental factors are we talking about? I am 
jumping right in because we don't have a lot of time.
    Mr. Insel. Sure. I know.
    Let me give you the numbers because this has gotten quite a 
bit of press and it is easy to misunderstand or over-interpret 
what they mean. This was the largest study done to date on 
twins. And we divide twins into those who are identical, where 
they share 100 percent of their DNA, and those who are 
fraternal, sharing 50 percent of their DNA, which is the same 
as you would expect from siblings.
    So just to cut to the chase, in the general population it 
rates about 110, so you can imagine sort of a 1 percent risk in 
the general population. If you have a sibling with autism, your 
risk goes up somewhere between 4 and 14 percent, depending on 
the study you look at. The new data with twins says that 
fraternal twins, for a diagnosis of autism spectrum disorder, 
would be in about the 31 percent concordance rate, and that is 
pretty high. So that is 30-fold higher than the general 
population. Identical twins with 100 percent DNA shared will be 
at 77 percent for autism spectrum disorder, a little bit lower 
for peer autism.
    So what this study ended up saying, and I think where the 
confusion has come from, is that on a basis of some very 
complicated mathematical modeling, that that represented about 
58 percent of the risk being environmental and about 38 percent 
being genetic, meaning more of this was environmental than 
genetic.
    Frankly I don't think that is helpful. I think it may be 
more useful to try to go after the complexity of this by 
understanding how environments and genetics interact. It is 
important to recognize that autism is really sort of an 
umbrella term and it is representing many different syndromes. 
Some of those syndromes are absolutely genetic: Fragile X, Rett 
syndrome, Tuberous Sclerosis, very, very high rates of autism 
in each of those. They all involve a genetic lesion. So in 
those cases you are talking about autism in the context of a 
genetic disease.
    There may be some, and we don't really know the number, in 
which the disorder is really generated by environmental factors 
yet to be determined. But there is a lot of research going on 
to try to track down what those could be. Much of the data that 
we have so far, and we are still I think early days on this, 
has been pointing to factors that impact second trimester, so 
prenatal or early postnatal factors in some cases. And there is 
a range of them that are coming particularly out of the UC 
Davis effort that is funded by, at this point, by NIH and by 
EPA and CDC where there is a number of things going on.
    In this case one of the things they are looking at, well, 
they have got not only the antidepressant study that you have 
already mentioned, but there are questions about environmental 
exposures to certain kinds of chemicals and fertilizers. There 
are questions about medications, particularly valproic acid, 
which has been raised as a likely insult. There are other 
issues around whether certain kinds of illness prenatally might 
predispose and be a risk factor.
    The bottom line is we still don't know. And we don't know 
of any factor that gives us more than a small amount of the 
risk that explains much of this increase.
    Mr. Pallone. Thank you, Mr. Chairman. Thank you.
    Mr. Pitts. Thank you. And the chair now yields to the 
gentleman from Ohio, Mr. Latta, for 5 minutes for questions.
    Mr. Latta. Well, thank you, Mr. Chairman. I appreciate the 
opportunity. And to our guests, thanks very much for being 
here. Both of these are subjects I know that all of us face 
when we go home with a lot of questions.
    And Dr. Heinrich, just recently I was over in Cleveland at 
the Rainbow Babies Hospital, and it is an incredible facility 
they have over there. And you know, just to give you a couple 
of statistics, you know, as we were talking about prior to the 
enactment of CHGME in 1999, in 2000 it showed that Rainbow 
trained 69 residents and 26 fellows; today the hospital is 
training 112 residents and 68 fellows. I guess the first 
question is if the CHGME is not extended, who will do this 
training?
    Ms. Heinrich. I don't think that there is any one of our 
programs that could make up the gap if the funding is not 
continued for the CHGME program. The children's hospitals are 
eligible for our ongoing competitive programs. For example, in 
our physician expansion program there were several children's 
hospitals that together I think were given about $13 million. 
The pediatric hospital residency programs can also apply to our 
ongoing primary care residency programs, for example, so they 
are eligible for other funding opportunities.
    Mr. Latta. Thank you. In your testimony on page 4, you say 
that approximately one-third of the CHGME payment goes for 
direct graduate medical expenses and two-thirds are for 
indirect graduate medical expenses. Can you tell me what those 
indirect medical expenses are?
    Ms. Heinrich. The indirect expenses may be expenses that 
the hospital identifies as associated with their training 
activity, whereas the direct expense is for support of the 
resident and for very specific training such as curriculum 
development or faculty.
    Mr. Latta. Thank you.
    And Dr. Insel, if I could ask you a couple of questions 
here in my remaining time. And I know that when I was in Ohio 
legislature quite a few years ago, I had quite a few families 
and groups I met with during that time. And one of the things 
that--could you tell me, when you were talking about the five 
general provisions, you used the word ``surveillance.'' How 
would you define surveillance?
    Mr. Insel. This is looking at the prevalence; that is, the 
number of--in this case it is 8-year-olds, there is a new study 
of 4-year-olds as well, who have a diagnosis of autism spectrum 
disorder.
    Mr. Latta. OK. And also, it shows in the last two decades 
ASD was considered a rare disorder, and now you are saying that 
1 in 110 children are being diagnosed with. What were those 
kids being diagnosed with before?
    Mr. Insel. That is a great question. We don't know how many 
of these children were diagnosed with some other disorder like 
childhood schizophrenia, sometimes mental retardation. One of 
the things that has changed over time is that you can now give 
a diagnosis of autism spectrum disorder and have one of these 
other diagnoses. Prior to 1991 that was not an option. But it 
still is not clear that all of these children had something 
else.
    One of the questions that I think we need to really grapple 
with is whether this is a real increase. And I think most 
people who have been in this field, as I have for more than two 
decades, would say that it is not simply changing diagnosis, it 
is not simply greater awareness, it is not simply ascertainment 
that is better, but that there is a true increase--as there is 
in asthma, Type I diabetes, and food allergies--there are more 
people affected with autism today than there were two decades 
ago.
    Mr. Latta. With my remaining minute to go, if I could just 
get two more questions in real quick. One is, you know, if a 
child is diagnosed before the age of two, what drugs are out 
there today that are working for them?
    Mr. Insel. For medications for what we now think of as a 
neurodevelopmental disorder, we are sitting pretty empty-
handed. We have medications that help on some of the secondary 
symptoms like helping with some of the temper tantrums, 
sometimes with some of the more compulsive behavioral pieces of 
this. But the reality is that the core symptoms--that is, the 
social deficits, problems in communication, some of this narrow 
attention--we don't really do very well with any medications. 
The best treatments have been behavioral. And those treatments 
in fact appear to be more effective when started early in life, 
18 to 24 months, rather than later after age 4.
    Mr. Latta. I see my time is up, and I yield back, Mr. 
Chairman. Thanks very much.
    Mr. Pitts. The chair thanks the gentleman, and yields to 
the gentleman from Michigan, the Ranking Member Emeritus, Mr. 
Dingell, for 5 minutes for questions.
    Mr. Dingell. Mr. Chairman, I thank you.
    These questions will be directed to Dr. Heinrich. Doctor, 
the questions here are going to be simplified to a yes or no 
answer. The Children's Hospital GME program was intended, as I 
recall it, to correct any unintentional disparity between the 
Federal Government's support for Graduate Medical Education 
that left children's hospitals without support, especially 
given the freestanding children's hospitals generally do not 
provide care to patients eligible to receive Medicare.
    Now, the question, do you feel that the Children's Hospital 
GME program was successful in addressing the disparity between 
freestanding children's hospitals in other teaching hospitals, 
yes or no?
    Ms. Heinrich. I believe it is yes.
    Mr. Dingell. Thank you. Now, in proposing to eliminate the 
Children's Hospital GME program, the President's budget 
justification called for a need to devote additional resources 
to train in primary care. The question: Are health services 
related to pediatrics considered to be primary care, yes or no?
    Ms. Heinrich. Yes.
    Mr. Dingell. Now, Doctor, are health services related to 
family medicine considered to be primary care, yes or no?
    Ms. Heinrich. If services to, I am sorry, family?
    Mr. Dingell. Well, let me repeat it. Are health services 
related to family medicine considered to be primary care?
    Ms. Heinrich. Family medicine, yes.
    Mr. Dingell. Now, Doctor, are health services related to 
internal medicine considered to be primary care, yes or no?
    Ms. Heinrich. Internal medicine before people 
subspecialize, yes.
    Mr. Dingell. Yes, thank you. Now, Doctor, my understanding 
is that 60 percent of the pediatricians trained by the 
Children's Hospital GME program are in general pediatrics, and 
hospitals in the program also provide pediatric training for 
residents in internal medicine and family medicine. Would you 
agree, then, that the Children's Hospital GME program helps to 
expand the primary care workforce, yes or no?
    Ms. Heinrich. Our numbers aren't as high as yours, but yes, 
part of what they--a number of the people that they train are 
in primary care.
    Mr. Dingell. Thank you, Doctor. Now, isn't this, then, in 
line with the President's goal of training additional 
physicians in primary care, yes or no?
    Ms. Heinrich. Part of the program is in line with the goal 
of increasing the number of providers in primary care, but we 
would say that it is important to focus our energy and our 
resources on the competitive programs.
    Mr. Dingell. So the answer is yes?
    Ms. Heinrich. Partially, yes.
    Mr. Dingell. Now, Doctor, in fiscal year 2000, the number 
of residents and fellows receiving Federal Children's Hospital 
Graduate Medical Education funding was a little over 4,200. 
Your testimony points out that in fiscal year 2010 the program 
supported approximately 5,800. The HRSA online performance 
index for the fiscal year 2012 budget submission notes that 
there has been continuous yearly growth between 3 and 6 percent 
in the number of resident full-time training equivalents at 
Children's Hospital since the inception of the program.
    Question: Would you agree that this increase in the number 
of trainees reflects the continuing need to train pediatric 
physicians, yes or no?
    Ms. Heinrich. Yes, we do feel that there is a need to 
continue to train pediatric residents.
    Mr. Dingell. And, Doctor, I want you to understand these 
are friendly questions, these are not hostile, we are not 
trying to push you into any sand traps or anything here.
    Now, in the 2010 application for the Children's Hospital 
GME funds, children's hospitals reported that half of their 
growth revenue for inpatient care and almost half of the growth 
revenue for outpatient care was for Medicaid and CHIP. Given 
that children's hospitals serve a large number of Medicaid and 
CHIP patients, as well as the uninsured, now the question, 
wouldn't you agree then, that these hospitals serve as an 
important safety net for families in need?
    Ms. Heinrich. I would have to go back and check on the 
numbers that you have provided.
    Mr. Dingell. I don't think the numbers are important, 
though, but they are substantial. And so can't we say on the 
basis, though, of almost any large numbers, that these 
hospitals are in fact an important safety net for families in 
need?
    Ms. Heinrich. I think that they are part of the safety net.
    Mr. Dingell. I guess I am over time. Thank you, Mr. 
Chairman, for your courtesy.
    Mr. Pitts. The chair thanks the gentleman, and now yields 5 
minutes to Dr. Burgess for questions.
    Mr. Burgess. Thank you, Mr. Chairman.
    Dr. Heinrich, help me if you can, understand what is going 
on with Dell Children's Medical Center in Austin, Texas. It 
established a new teaching program in 2007, at a time Federal 
regulations said that new programs could receive children's 
graduate education funding if they were accredited as a new 
program by an accrediting body such as the Accreditation 
Council for Graduate Medical Education.
    Then two years later in 2009, HRSA had a change of heart, 
and although Dell had been receiving funding for 2 years as an 
accredited teaching program, HRSA notified Dell that because of 
an interpretation by the Centers for Medicare and Medicaid 
Services to protect Medicare funds, Dell would no longer be 
receiving that funding.
    Now, my understanding is that HRSA made that decision 
because CMS clarified its rules regarding which programs could 
qualify as new. The regulations issued at the time indicated 
that this change by CMS was undertaken to protect Medicare 
entitlement funds; is that correct?
    Ms. Heinrich. It certainly was associated with the CMS 
regulations on the determination of a new program.
    Mr. Burgess. Well, and the protection of entitlement funds, 
which would be under the jurisdiction of the Center for 
Medicare and Medicaid Services. So the rules are in place to 
protect Medicare funds, but considerations are very different 
for a Children's Graduate Medical Education program because 
they are funded with discretionary funds and grants. We 
appropriate those funds as part of the annual appropriations 
process.
    So why the discrepancy there? Why are discretionary funds 
appropriated by the Congress being withheld as if they were 
mandatory funds being administered by CMS?
    Ms. Heinrich. I can't respond specifically to the different 
funding source and what difference that makes.
    Mr. Burgess. Well, look, all through the continuing 
resolution debate, we were told we couldn't touch entitlement 
funding because we were only dealing with discretionary money 
in the continuing resolution. OK, now the shoe is on the other 
foot and we have got appropriations discretionary funding going 
to Children's Graduate Medical Education, Dell Children's 
Hospital, Austin, Texas. And you are saying that because we are 
protecting mandatory funding, you can't have that money 
anymore.
    I guess what I would ask is, will you work with me and my 
office to see if we can resolve this if there is a legislative 
fix that is needed so that people understand more clearly their 
individual roles in this? I think it is a--it is bound to just 
be an oversight, but it is one of those things that we have to 
fix because the money is not going where it was intended.
    Ms. Heinrich. We would be very happy to work with you and 
your office in looking into this.
    Mr. Burgess. Well, let me ask you another question. The 
HRSA Online Performance Index for your fiscal year 2012 budget 
submission, it states ``the program''--speaking of Children's 
Graduate Medical Education--``the program also improves access 
to health care by expanding the capacity of the health care 
safety net at freestanding children's hospitals for underserved 
children and families.''
    So that is correct, right?
    Ms. Heinrich. Yes.
    Mr. Burgess. Well, why was the administration's choice then 
to zero out the budget for Children's Hospital Graduate Medical 
Education in 2012? It apparently worked, but you are zeroing 
out the funding. Can you help us understand why that would be?
    Ms. Heinrich. In these challenging budget requirements, it 
is very difficult; and we have to make very difficult choices.
    Mr. Burgess. I get that, because we are knee-deep in that--
neck-keep in that right now.
    Ms. Heinrich. Yes.
    Mr. Burgess. But, again, according to your own views and 
estimates on the Web, this program is working; and yet the 
President chose to zero it out. It just doesn't seem to make 
sense.
    Ms. Heinrich. It is a very hard choice to decide which of 
the programs when you have to make cuts must be cut.
    Mr. Burgess. Dr. Insel, but I run out of time, let me just 
ask you a question. You gave us some rather dramatic figures 
of--was it, in male children, one out of every 80?
    Mr. Insel. One in 70.
    Mr. Burgess. One in 70. That was the 8-year-old cohort. You 
have been at the NIH since 2002, so you have seen that 8-year-
old cohort double in age. Do any of these children age out of 
the process? What is happening now with those 16-year-olds? Is 
it one in 70 16-year-olds?
    Mr. Insel. Generally, children with autism become teenagers 
with autism, become adults with autism. They may adapt. They 
may be better to function better. Many of these children are 
able to go through a regular school system but only with a 
great number of supports and often a very extensive and 
intensive set of behavior therapies. The average estimate for 
cost over a lifetime is $3.2 million per person on the 
spectrum.
    Mr. Burgess. Thank you, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman and yields to the 
gentleman from Kentucky, Mr. Guthrie, for 5 minutes for 
questioning.
    Mr. Guthrie. Thank you, Mr. Chairman, and thank you, Dr. 
Heinrich, for coming. I am going to focus most of my questions 
on Dr. Insel.
    But I have a lot of people that contact me about autism. I 
am from Bowling Green, Kentucky. The Kelly Autism Center is a 
new part of Western Kentucky University that an entrepreneur's 
family started when their grandson was diagnosed with autism. 
So it touches all families, all places.
    You kind of highlighted on some focus, so what I am going 
to do is kind of cede my time to you to kind of get through, if 
you would--you focused on second trimester with some things 
that you are focusing on. What are you seeing? What is on the 
horizon? I know you said you put a plan together. I know there 
are a lot of unknowns.
    You have 4 minutes. I know you ran out of time on your 
testimony. Can you give just an overview of where we are and 
where we think we are going?
    Mr. Insel. Sure. Very quickly, what we often do in science 
is go where we have the most traction; and, right now, that is 
in genetics. The cost of doing a human genome has gone from $2 
billion to $2,000 in the time that I have been at NIH, which is 
less than 10 years. So that gives you some mileage. And doing 
that has been informative, even in the last couple of months 
where we have been able to use the power of genomics to 
identify mutations that we didn't know were present that seemed 
to be associated with high risk and, in some cases, may be 
causative for autism.
    But, clearly, that is going to hit a wall. I think what we 
are going to discover is that that will explain part of the 
population; and I don't think it is going to explain the 
increase, because your genome doesn't change over two decades.
    So the interest now is in increasingly looking at what 
could be the environmental factors that are hitting those 
people who are genetically susceptible; and, as I was saying 
before, we have a very short list at this point because this is 
in some ways a relatively new area of investigation. And, to be 
honest about it, we don't have the traction in finding 
environmental factors that we do have in finding genetic 
sequence changes. So this is a long, expensive, and difficult 
process that mostly deals with large population studies and 
goes after correlations. So it is not quite the same as what we 
have been doing in genetics.
    That said, there are a number of projects under way, some 
of which are looking at younger siblings where we know there is 
a great risk, picking them up as soon you have a positive 
pregnancy test and following them. Some are looking at large 
birth cohorts, both in Norway, Denmark, and now in the United 
States. Some are looking in great detail at environmental 
factors across both pregnancy and the first 3 years of life.
    All of those, when done longitudinally, may begin to flesh 
out some signals, but right now the signals we have are 
relatively week. They may show, like with the antidepressants, 
perhaps a two-, maybe even a threefold increase in risk, but 
nothing like the 70-fold increase in risk you have for having 
an identical twin.
    Mr. Guthrie. OK. And that is where we are, kind of the 
state of the art where we are. Where do you think we will be in 
the next--I know it is maybe just guessing.
    Mr. Insel. I think part of the reason why I said there is 
some confusion about genetics versus environment is I think 
where we may end up is learning to use the power of genomics to 
actually finding environmental factors. So one of the things we 
know about from cancer research, for instance, is that 
environmental factors through somatic mutations on particular 
cells lead to changes in cell division and increased risk for 
tumor formation.
    The same thing could be happening in the brain. We don't 
know that. The same thing could be happening in the germ cells 
that create the fetus. All those are opportunities to begin to 
track down changes in the genome, either because they are 
mutations or because they are modifiers of how the genome is 
read. And that is what the environment does. The environment 
can do that.
    So we may be able to find the footprints of environmental 
exposures by looking at the genome long after they take place. 
We are not there yet, but we now are getting the tools--and by 
``now'' I mean in the last year or two--we have the tools to 
begin to do this with great precision and great throughput. And 
at that point I think we will be able to make a little more 
progress than we have to look for environmental causes.
    Mr. Guthrie. Thank you.
    I will use my last 30 seconds, just a couple of seconds, 
just to compliment what is happening in Bowling Green with the 
Kelly Autism Program. I don't know if you are familiar with it 
or not, but Suzanne Vitale, who is the grandmother of Philip 
Proctor, I guess he is about 11 now, maybe 12, and performs in 
plays and things like that. So if you put intensive therapy 
into someone, it can really help. They have the resources to do 
so. We just need to get the resources here as we want other 
kids to have the same opportunities.
    Mr. Insel. Well, thank you. There is no group of people 
that I have met that are more inspiring than the families of 
people with autism. These are really dedicated parents who make 
things happen.
    Mr. Guthrie. Thank you.
    I am out of time. I yield back.
    Mr. Pitts. The chair thanks the gentleman and recognizes 
the gentleman from Georgia, Dr. Gingrey, for 5 minutes of 
questioning.
    Mr. Gingrey. Mr. Chairman, thank you.
    I will go to Dr. Heinrich first.
    Dr. Heinrich, these questions I think have already been put 
to you maybe a little bit by Chairman Emeritus Dingell, but I 
would like to get you to respond once again. In proposing to 
eliminate the Children's Health Graduate Medical Education, the 
President's budget justification called for a need to devote 
additional resources to train in primary care. Yet--and I think 
you may have said this--60 percent of the pediatricians trained 
by CHGME hospitals are in general pediatrics, primary care; 
and, additionally, the Health Graduate Medical Education 
hospitals provide pediatric training for residents in internal 
medicine and family medicine. And you had stated to Mr. Dingell 
that both of those were primary care, particularly internal 
medicine, before they go on to subspecialize. How is it that 
this administration does not recognize that Children's Health 
Graduate Medical Education hospitals provide essential support 
for the future primary care workforce for our Nation's 
children?
    Ms. Heinrich. We are not saying that this isn't a 
successful program. Our latest figures are that about 46 
percent of the resources are going into general pediatrics, 
maybe 27 percent to the pediatric subspecialists, and then 
another 27-28 percent that go to the other residents who rotate 
through the children's hospitals. We are simply saying that in 
this environment you have to make hard choices; and, in this 
instance, that is what we have done for the 2012 budget 
request. We are also saying that pediatricians can be trained 
in other facilities and can be trained through other types of 
programs.
    Mr. Gingrey. Thank you.
    Dr. Insel, the research on autism conducted at the Autism 
Centers of Excellence have been described by some as being 
redundant and too focused maybe on gene and diagnosis research 
and not on, for example, things like autoimmune problems. In 
addition, there is concern that administrative costs are too 
high and they take away much-needed funds from research. 
Comment on these criticisms for me, if you will. And I will 
have a follow-up question: Do you believe that autism research 
efforts are well coordinated?
    Mr. Insel. Well, there are 11 Autism Centers of Excellence. 
They represent about altogether less than $25 million of the 
investment from NIH, which is now about $218 million for 2010. 
So they are just a little bit more than perhaps 10 percent of 
our investment.
    They are places where there is a wide range of research. 
Some of it does in fact involve genetics. But one of the most 
recent networks funded is all about environmental factors, the 
early--and early in this case stands for early autism risk 
longitudinal investigation study, which is pulled together by 
Drexel University, Dr. Newschaffer, looking at actually the 
long-term exposure history for people who are at risk for 
autism. So I wouldn't think it would be accurate to say that 
they are only about the genetics of autism. That is one of the 
things that happens. There is also treatment development, 
biomarkers, a whole range of things that are going on in those 
centers.
    What about the coordination? I think that one of the 
successes of the IACC has been to increase coordination not 
only within the Federal agencies, where you see CDC and NIH and 
HRSA working much better on many of these questions, but 
perhaps in this area most importantly between the Federal 
agencies and some of the private foundations.
    Autism is a little unusual in the world that I live in, 
because this is a place where there is quite a bit of private 
money now coming in to support research in a very exciting way. 
And that is----
    Mr. Gingrey. Let me interrupt you for a second, because I 
am about to run out of time, and I did want to ask you one last 
question.
    In your testimony, you talked about identical twins and the 
prevalence of autism in regard to--my question really is, why 
isn't it 100 percent? If you have got--it is either DNA or 
genetic-related or environmental, and you say, who knows, 60-
40, 50-50, 40-60. But those identical twins obviously have the 
exact same DNA and they have been exposed, as has their mom, to 
the exact same environment, certainly through 1-and-a-half to 2 
years of age. So why isn't it 100 percent?
    Mr. Insel. Right. So it is important to remember that 
autism is not cystic fibrosis, Huntington's Disease, or a 
number of other single-gene, truly genetic disorders. In fact, 
it is not a single disorder. When we use the term autism, it is 
like talking about epilepsy, or maybe talking about fever. 
There are many, many different syndromes that end up in this 
umbrella term. Some of them, as I mentioned before, may truly 
be 100 percent genetic; and in those twins, if one has fragile 
X, the other will have fragile X, and they may both have 
autism.
    But that doesn't cover more than perhaps 15 percent of the 
population as we know it right now. And for the rest, many 
disorders that are in this umbrella, under this umbrella, there 
may be many other sorts of ways to think about how to get 
there, and some of them could be environmental.
    Mr. Gingrey. Thank you, and I yield back.
    Thank you, Mr. Chairman.
    Mr. Pitts. The chair recognizes the gentleman from 
Louisiana, Dr. Cassidy, for 5 minutes nor questions.
    Mr. Cassidy. Again, I only have 5 minutes, if I cut you 
off.
    I am trying to get my head around--so, previously, CHGME 
for pediatrics got roughly how much money and then how much in 
this latest budget?
    Ms. Heinrich. OK. For the CR for 2011, we are funding it at 
$268 million; and in fiscal year '10 it was $317 million.
    Mr. Cassidy. And the President's budget zeroed it out?
    Ms. Heinrich. For 2012.
    Mr. Cassidy. Wow. Now, I am an internist. I am actually 
still on the faculty with an internal medicine program. And 
although there is collaboration between internal medicine, I 
find really pediatrics has their own gig going and internal 
medicine may have their own, and that is important. So if HRSA 
is going to be attempting to be all things to all specialties, 
in practice I just don't see that working as well. What do you 
imagine HRSA will dedicate towards pediatric training as it is 
dividing up this pool in different primary training 
specialties?
    Ms. Heinrich. Well, as you know, most of the training for 
physicians at the residency level are funded by Medicare GME, 
and we have a relatively small portion. The focus of this 
administration is to expand the primary care----
    Mr. Cassidy. But how much will this HRSA-type funding 
mechanism result in going to pediatric programs? You have been 
getting roughly $270 million. How much will result under the 
Obama budget?
    Ms. Heinrich. Within the competitive programs that we have 
for the primary care providers, it would really depend. It will 
depend on how----
    Mr. Cassidy. But you must have a ballpark.
    Ms. Heinrich. I don't, because----
    Mr. Cassidy. In that case, if I was a pediatric program, I 
would see a train coming down a tunnel. Because I would say, 
oh, my gosh, they have no clue how much they are going to be 
allocating towards pediatric programs.
    Is there no sense at all of how much--because autism is a 
pediatric disease, and our ability to train primary care 
pediatrics to do the 5-minute exam will in part depend upon the 
effectiveness of HRSA pulling this off. So HRSA has no 
guidelines or projections how much will be going to pediatric 
hospitals?
    Ms. Heinrich. The pediatric hospitals would be part of a 
competition that we would have, say, for primary care 
providers.
    Mr. Cassidy. I see that, but I guess we keep talking past 
each other. My specific question is, and it sounds like you 
don't, do you have a sense of how much money will be going to 
these programs to replace the $270 million being lost?
    Ms. Heinrich. You are right. We do not know that.
    Mr. Cassidy. That is frightening. There just seems there 
should be some sort of proactiveness involved.
    Dr. Insel, in the spectrum of ASD, I gather there are some 
people now in the ASD kind of group who formally may not have 
been recognized and may have just kind of gone through life 
always thought to be a little odd but now they are actually 
diagnosed. Is that a fair statement?
    Mr. Insel. It is.
    Mr. Cassidy. Now, you mentioned--very frightening--the $3 
million cost to society for untreated--for a person who is a 
member of the ASD group, if you will, diagnostic group, that 
$3.2 million, I assume that is for the kind of full-blown, not 
for the person who is marginal who previously would not have 
been recognized but now is included in a diagnostic spectrum. 
Is that fair?
    Mr. Insel. Correct.
    Mr. Cassidy. So what percent of the entire group so 
diagnosed with ASD would be those that would consume a large 
amount of future societal resources? Be it prison, be it 
neuralgic service, you name it.
    Mr. Insel. I can't give you a precise number for that.
    Mr. Cassidy. Can you give me a ballpark?
    Mr. Insel. I would say it is somewhere between 50 and 60 
percent of people who are on the spectrum are going to be in 
that group of people who would have been, by the way, 
identified 20 years ago because they don't have a subtle 
problem.
    Mr. Cassidy. Right. They are the ones that are going to 
consume more.
    I don't mean to be rude. I am almost out of time. What is 
going to be the cost of society and what is the potential of 
early intervention to diminish that cost?
    Mr. Insel. We have a good sense of the latter part. We know 
that early intervention for about half of these children--
``early'' meaning before 24 months--can lead to not only great 
improvement in IQ and adaptive behavior but potentially even to 
loss of diagnosis. So that is fairly impressive.
    The cost to society which we have tried to model out in 
various ways, I would have to submit that for the record. But I 
can tell you that the $3.2 million, on average, you can 
multiply, just to give you a ballpark, times what we think are 
the 700,000 people who are on this spectrum, and it is fair to 
say that somewhere around 500,000 are going to be on the severe 
end of the spectrum or will be in that range that is going to 
require additional support.
    Mr. Cassidy. I am over time. I could take more.
    If you could just send that as a response, the kind of a 
complete spreadsheet of this is the percent that will require 
more services and this is the mean. I say that not to impose 
upon you, but that will help guide public policy.
    Mr. Insel. I am happy to help.
    Mr. Cassidy. I yield back. Thank you both.
    Mr. Pitts. The chair thanks the gentleman.
    Without objection, the chair recognizes Dr. Christensen, 
who is not a member of the subcommittee, but is here and would 
like to ask questions for 5 minutes.
    Mrs. Christensen. Thank you, Mr. Chairman, and thank you, 
Ranking Member, as well for allowing me to sit in on this very 
informative hearing on two bills that really, as you can hear, 
enjoy bipartisan support.
    I guess I would ask Dr. Insel first, but I am really amazed 
and really pleased to have been able to read in your testimony 
all of the advances that are taking place in autism spectrum 
disorder. I am seeing a lot more attention paid to it in my 
district as well. So I want to commend the IACC for all of the 
work that has been done in these 10 or so years. I can't see 
how we could have had the same kind of coordination without the 
committee. So I want to thank you and the committee members for 
your service.
    My question is related to some of the health disparities we 
deal with, Dr. Insel. Given the lesser access to quality health 
care that is experienced by racial and ethnic minorities and 
the often-reported under-diagnosis of some disabilities and 
mental illness in these groups, are you seeing disparities in 
the diagnosis and treatment of ASD in people of color? And, if 
so, does the IACC have a plan to address it?
    And just an additional part to that question, are the 
territories included in your outreach to the public and 
providers?
    Mr. Insel. Well, thank you for those questions.
    Yes, the disparity is there. There is nothing unique about 
autism in terms of health equity. We have many of the same 
problems you see in the rest of health care.
    The difference here, though, may be a little more profound 
in the sense that where we see the greatest disparity is the 
age of diagnosis. Children are diagnosed, but not at age 4 but 
at age 6. And remember what I said before, that the early 
interventions appear to have the most profound improvements, 
the greatest impact on prognosis. So you have lost a real 
opportunity there to have that kind of an impact. So this is 
enormously important.
    The strategic plan, especially the one that is out in 2011, 
it mentions specifically the importance of having a diverse 
portfolio in terms of looking at many different communities and 
making sure that issues around health disparities are 
addressed. That is a major piece of it.
    I should just finish by saying that I don't believe the 
territories itself have been an area of outreach, but I can 
again find out more about that and submit that for the record.
    Mrs. Christensen. Thank you.
    My understanding is in children with disabilities in the 
U.S. Virgin Islands specifically, it is somewhere about 4 to 5 
percent of those children are diagnosed with ASD.
    Dr. Heinrich, what percent of pediatric residents are 
supported by this CHGME? I know we have talked about what 
percentage of the pediatric residents are in primary care. But 
is it about half?
    Ms. Heinrich. It probably is about half, but I could get 
back to you with the specific number, if you wish.
    Mrs. Christensen. OK. And are there any plans in place, 
given the passage of the Patient Protection and Affordable Care 
Act and the increase in the number of individuals or families 
that will be covered, for what kind of an increase in pediatric 
primary care you might need? I realize we have Medicaid and 
SCHIP. But have there been any projections?
    Ms. Heinrich. We don't have a projection specifically for 
pediatrics, but we have expanded the primary care workforce 
through the Affordable Care Act in 2010 and continue some of 
that in 2011. So, for example, we have funded additional 
primary care residency training programs, and there were about 
six children's hospitals that are participating in that 
program. They did very well. We are also expanding the nurse 
practitioner primary care programs and the PA primary care 
programs, for example.
    Mrs. Christensen. Let me see if I can get another question 
in.
    My original plan was to go into adolescent medicine, 
although I decided to do it through family medicine, but you 
still probably paid for part of my pediatric training. Do you 
have input into the design of the training programs in the 
pediatric residencies that you support and do you see any 
specific attention being paid to that adolescent population 
that has unique needs that are not necessarily what we consider 
pediatric?
    Ms. Heinrich. We don't design the curriculum or the 
training programs. Those are really determined by the 
accrediting bodies, if you will. Of course----
    Mrs. Christensen. Is there consideration for whether you 
fund them or not?
    Ms. Heinrich. Well, the law requires that any entity that 
qualifies can participate in the program. But in the law it 
does say that there will be special attention to underserved 
populations and quality, for example, so that is stipulated in 
the law.
    Mr. Pitts. The chair thanks the gentlelady.
    That completes the first rounds of questions. We will go to 
one follow-up on each side.
    The chair recognizes Dr. Burgess for 5 minutes for follow-
up.
    Mr. Burgess. Thank you, Mr. Chairman.
    Dr. Insel, I apologize for being out of the room when Dr. 
Gingrey's questions were being asked, but let me just be sure I 
understand correctly. I think the concern that was being 
addressed there was that the general and accounting side of the 
ledger is consuming more of the dollars that then can't go to 
the R&D side of the ledger. Is that basically the tension that 
is there?
    Mr. Insel. I am afraid I don't follow the question.
    Mr. Burgess. Are we spending more for the centers than we 
are getting in excellence? Are we spending more for the 
administrative side than we are getting on the research side?
    Mr. Insel. Well, the centers are all research centers. So 
the centers of excellence are part of----
    Mr. Burgess. Who is responsible for constructingthe budget 
and the oversight of that budget? Is that NIMH or is that NIH?
    Mr. Insel. I think it is the National Institute of Child 
Health and Human Development.
    Mr. Burgess. Perhaps they could provide us, Mr. Chairman, 
with--what would be reasonable--the last 3 years of budgetary 
figures?
    Mr. Insel. I can give you--I mean, the range is between 22 
and 26 million, depending on how you cut that pie over the last 
3 years. Overall funding in 2010 for NIH was $218 million. So, 
as I said, it is roughly about 10 percent of our overall 
investment in autism research.
    Mr. Burgess. On the breakdown of the autism research 
dollars themselves, I guess the discomfiture is there are those 
that say we are spending more for overhead than we are actually 
getting in research.
    Mr. Insel. So--I apologize. I didn't really understand 
where you were going.
    So the centers are the research centers. The overhead, 
which is true across our entire portfolio, is quite a different 
matter. So it doesn't matter whether we are paying an 
individual grantee or paying a center. The overhead rates are 
going to depend on the institution that the money goes to, and 
that overhead generally averages out about 50 percent or a 
little bit more for most institutions.
    Mr. Burgess. That seems high, but maybe it has just been 
too many years that I have been involved on the research end. 
But if you could provide us with some of those budgetary 
figures, I think that would be helpful.
    Mr. Insel. Just so I understand, what you would like to see 
are what the overhead figures are within the autism realm----
    Mr. Burgess. You have 12 centers of excellence?
    Mr. Insel. Eleven.
    Mr. Burgess. Within those 11 centers of excellence.
    Mr. Insel. I would be happy to provide that.
    Mr. Burgess. Well, let's take then just a broader view of 
your world. You know, advances in brain science have been 
occurring at a significantly more rapid rate the past decade 
than any decade prior; and whether it be Alzheimer's, traumatic 
brain injury, autism, you guys are accumulating a vast body of 
knowledge. What do you see over the horizon? Are you learning 
things in your study of autism that are helpful in other areas 
of brain science, like those suffering with Alzheimer's and 
those suffering with traumatic brain injury?
    Mr. Insel. Very much so. In fact, one could ask why is NIMH 
leading the charge on autism when autism is usually considered 
either a neurological or pediatric disorder and not necessarily 
a classical or prototypical mental illness. And yet for us this 
has been the prototype that we have wanted to follow. We think 
about all mental illnesses increasingly as neuro-developmental. 
The difference is that the symptoms of schizophrenia start at 
age 18 rather than age 3 or 2 in autism. But many of the 
aspects of the biology, the biology mostly having to do with 
how neurons connect and how they develop. So we tend to now 
think about autism as a synaptic disease; and we are 
increasingly talking about schizophrenia, mood disorders, other 
disorders, as synaptic diseases as well. So I think we are 
going to learn from autism important insights that will play 
out all across the spectrum of neuro-development.
    Mr. Burgess. And with the last reauthorization at the 
National Institutes of Health, the provision was made for 
translational research which gave the director, in this case 
Dr. Collins, some discretionary authority that the director had 
not had before. Do you see this as being something that has 
been helpful as far as being able to work across the various 
silos and agencies within the institute?
    Mr. Insel. Absolutely. And I would say that Dr. Collins' 
focus on translational science here couldn't be more urgent for 
autism. I think you may have been out of the room when I 
pointed out that, even though this is considered a 
developmental brain disorder, the only treatments we have at 
this point are behavioral, that is the treatments for the core 
symptoms that are effective. So we have an urgent need to 
create a pipeline for medications that might help. Perhaps they 
would be medications that would make behavior therapy more 
effective.
    Mr. Burgess. Correct. That behavior therapy seems to be 
labor intensive and expensive, if I caught the end of your 
comments to Dr. Cassidy correctly.
    Mr. Insel. Yes.
    Mr. Burgess. Thank you for your time, Mr. Chairman. I yield 
back.
    Mr. Pitts. The chair thanks the gentleman and recognizes 
the ranking member, Mr. Pallone, for 5 minutes for follow up.
    Mr. Pallone. Thank you, Mr. Chairman.
    I know you mentioned, as the chair of the IACC, you 
described many efforts and apparently many successes which have 
resulted from your committee's work. In the coming weeks, our 
committee is going to be taking up a proposal to grant the 
Secretary explicit authority to establish on her own 
coordination committees for specific diseases and conditions 
without additional authorizing language. As we consider this 
proposal, it would be helpful to get your insights on what 
worked and what didn't work, you know, what worked best or what 
didn't work in terms of the IACC's own activities. So I wanted 
to ask you, in your own words, why has the IACC apparently 
succeeded in actually doing what the Combating Autism Act 
intended, and then what elements or operations of the committee 
made it work so well?
    Mr. Insel. Well, I wouldn't want to suggest for a moment 
this has been easy. I mean, I think it has been successful, but 
there have been a lot of bumps in the road, and I think we have 
learned along the way.
    I have to say this is an area where I believe many members 
of the autism community felt that the government wasn't 
responsive and that the Federal agencies were asleep at the 
wheel. And I think one of the things the IACC has done is to 
make those people in the community--and this is a very diverse 
community--but making that diverse group of participants, 
keeping them as really part of the process and making sure that 
not only did we listen to them but they had a chance to hear 
what we struggled with, and we could do a number of things 
together.
    One of the things that has been perhaps most gratifying for 
us--and I am not sure how well this would work in other areas--
is the opportunity to actually create specific public-private 
partnerships around key projects. A huge issue in autism is the 
physical health of children with autism. They have lots of 
problems besides the behavioral ones I described. Yet we didn't 
have good best practices for how to deal with sleep 
disturbances, how to deal with seizures, how to deal with some 
of the gastrointestinal problems that are really quite common 
in some children with autism.
    So one of the things that came out of an effort from Autism 
Speaks, which is one of the foundations for autism, was to 
create a the national network called the Autism Treatment 
Network, ATN, 17 sites across the country. We could partner 
with them. HRSA has also partnered with Autism Speaks on the 
same network.
    That has I think been a big part of the success, is 
creating those kinds of partnerships that might have been 
difficult to do without the IACC as a forum to get those needs 
and to also prioritize the needs all at one time.
    Mr. Pallone. I appreciate that.
    I yield back, Mr. Chairman.
    Mr. Pitts. The chair thanks the gentleman.
    That concludes our questioning for the panel, excellent 
panel, very informational.
    This will conclude today's hearing. I remind members that 
they have 10 business days to submit questions for the record, 
and I ask the witnesses to please agree to respond promptly to 
the questions.
    The subcommittee is adjourned.
    [Whereupon, at 3:32 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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